Provider Demographics
NPI:1740905041
Name:KELLY, BRIAN NEIL (RPH)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:NEIL
Last Name:KELLY
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6216 JERICHO TPKE
Mailing Address - Street 2:
Mailing Address - City:COMMACK
Mailing Address - State:NY
Mailing Address - Zip Code:11725-2801
Mailing Address - Country:US
Mailing Address - Phone:631-219-6615
Mailing Address - Fax:
Practice Address - Street 1:80 SEAVIEW BLVD
Practice Address - Street 2:
Practice Address - City:PORT WASHINGTON
Practice Address - State:NY
Practice Address - Zip Code:11050-4618
Practice Address - Country:US
Practice Address - Phone:516-626-2799
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-10
Last Update Date:2022-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY047032183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist