Provider Demographics
NPI:1891255592
Name:KELCZ, MICHAEL JOHN (PHARMD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:JOHN
Last Name:KELCZ
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8914 157TH AVE
Mailing Address - Street 2:
Mailing Address - City:HOWARD BEACH
Mailing Address - State:NY
Mailing Address - Zip Code:11414-2728
Mailing Address - Country:US
Mailing Address - Phone:917-655-1207
Mailing Address - Fax:
Practice Address - Street 1:73 COVERT AVE
Practice Address - Street 2:
Practice Address - City:FLORAL PARK
Practice Address - State:NY
Practice Address - Zip Code:11001-3218
Practice Address - Country:US
Practice Address - Phone:516-354-1227
Practice Address - Fax:516-354-0974
Is Sole Proprietor?:No
Enumeration Date:2019-03-20
Last Update Date:2019-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY065268183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY065268OtherNYS PHARMACY LICENSE