Provider Demographics
NPI:1720338429
Name:RAFTERY, KEVIN J
Entity Type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:J
Last Name:RAFTERY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3217 BEACH CHANNEL DR # A
Mailing Address - Street 2:
Mailing Address - City:FAR ROCKAWAY
Mailing Address - State:NY
Mailing Address - Zip Code:11691-1502
Mailing Address - Country:US
Mailing Address - Phone:718-868-2200
Mailing Address - Fax:718-868-1518
Practice Address - Street 1:3217 BEACH CHANNEL DR # A
Practice Address - Street 2:
Practice Address - City:FAR ROCKAWAY
Practice Address - State:NY
Practice Address - Zip Code:11691-1502
Practice Address - Country:US
Practice Address - Phone:718-868-2200
Practice Address - Fax:718-868-1518
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-11
Last Update Date:2012-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY046427183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist