Provider Demographics
NPI:1790804755
Name:IZYDORCZAK, KELLY C (RPH)
Entity Type:Individual
Prefix:MR
First Name:KELLY
Middle Name:C
Last Name:IZYDORCZAK
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:793 WARREN DR
Mailing Address - Street 2:
Mailing Address - City:EAST AURORA
Mailing Address - State:NY
Mailing Address - Zip Code:14052-1925
Mailing Address - Country:US
Mailing Address - Phone:716-655-3582
Mailing Address - Fax:
Practice Address - Street 1:650 MAIN ST
Practice Address - Street 2:
Practice Address - City:EAST AURORA
Practice Address - State:NY
Practice Address - Zip Code:14052-2423
Practice Address - Country:US
Practice Address - Phone:716-652-1813
Practice Address - Fax:716-652-4230
Is Sole Proprietor?:No
Enumeration Date:2007-03-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY040143183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist