Provider Demographics
NPI:1881046795
Name:BLY, CASEY A
Entity type:Individual
Prefix:
First Name:CASEY
Middle Name:A
Last Name:BLY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:41 LOWER NEW TOWN RD
Mailing Address - Street 2:
Mailing Address - City:WATERFORD
Mailing Address - State:NY
Mailing Address - Zip Code:12188-1219
Mailing Address - Country:US
Mailing Address - Phone:518-391-5219
Mailing Address - Fax:
Practice Address - Street 1:236 MAIN ST
Practice Address - Street 2:
Practice Address - City:NEW PALTZ
Practice Address - State:NY
Practice Address - Zip Code:12561-1314
Practice Address - Country:US
Practice Address - Phone:845-255-9210
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-05
Last Update Date:2016-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY061707183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist