Provider Demographics
NPI:1942577242
Name:KELLY, DALISSA RUBI (PHARMD)
Entity Type:Individual
Prefix:
First Name:DALISSA
Middle Name:RUBI
Last Name:KELLY
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1167 WASHINGTON ST.
Mailing Address - Street 2:T-2532
Mailing Address - City:HANOVER
Mailing Address - State:MA
Mailing Address - Zip Code:02339
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1167 WASHINGTON ST.
Practice Address - Street 2:T-2532
Practice Address - City:HANOVER
Practice Address - State:MA
Practice Address - Zip Code:02339
Practice Address - Country:US
Practice Address - Phone:781-499-1962
Practice Address - Fax:781-499-1972
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-30
Last Update Date:2011-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPH27690183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist