Provider Demographics
NPI:1851439996
Name:KELLY, ELLEN P (RPH)
Entity Type:Individual
Prefix:
First Name:ELLEN
Middle Name:P
Last Name:KELLY
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 1:509 POPLAR ST
Mailing Address - Street 2:
Mailing Address - City:MAYFIELD
Mailing Address - State:PA
Mailing Address - Zip Code:18433-1800
Mailing Address - Country:US
Mailing Address - Phone:570-876-3946
Mailing Address - Fax:570-876-3946
Practice Address - Street 1:509 POPLAR ST
Practice Address - Street 2:
Practice Address - City:MAYFIELD
Practice Address - State:PA
Practice Address - Zip Code:18433-1800
Practice Address - Country:US
Practice Address - Phone:570-876-0740
Practice Address - Fax:570-876-3946
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-01
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARP031370L183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0008734770001Medicaid
PA1028750001Medicare ID - Type Unspecified