Provider Demographics
NPI:1649495573
Name:ANDERSON, KELLY LYNN (RPH)
Entity type:Individual
Prefix:MISS
First Name:KELLY
Middle Name:LYNN
Last Name:ANDERSON
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 1:4097 CENTER STREET EXT
Mailing Address - Street 2:
Mailing Address - City:SALAMANCA
Mailing Address - State:NY
Mailing Address - Zip Code:14779-9730
Mailing Address - Country:US
Mailing Address - Phone:716-307-0665
Mailing Address - Fax:
Practice Address - Street 1:987 R C HOAG DR
Practice Address - Street 2:
Practice Address - City:SALAMANCA
Practice Address - State:NY
Practice Address - Zip Code:14779-1365
Practice Address - Country:US
Practice Address - Phone:716-945-5894
Practice Address - Fax:716-945-5681
Is Sole Proprietor?:No
Enumeration Date:2007-04-16
Last Update Date:2010-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY046305-01183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist