Provider Demographics
NPI:1881712230
Name:MOON, KELLY J (RPH)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:J
Last Name:MOON
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 1:32 DURAND ST
Mailing Address - Street 2:
Mailing Address - City:FREWSBURG
Mailing Address - State:NY
Mailing Address - Zip Code:14738-9537
Mailing Address - Country:US
Mailing Address - Phone:716-569-4331
Mailing Address - Fax:716-661-4833
Practice Address - Street 1:12 CARROLL ST
Practice Address - Street 2:
Practice Address - City:JAMESTOWN
Practice Address - State:NY
Practice Address - Zip Code:14701-4755
Practice Address - Country:US
Practice Address - Phone:716-661-1520
Practice Address - Fax:716-661-4833
Is Sole Proprietor?:No
Enumeration Date:2007-03-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY037498183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist