Provider Demographics
NPI:1902029291
Name:KELLY, ROBERT J (RPH)
Entity Type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:J
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:PO BOX 244
Mailing Address - Street 2:
Mailing Address - City:PALOS PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60464-0244
Mailing Address - Country:US
Mailing Address - Phone:708-715-9674
Mailing Address - Fax:
Practice Address - Street 1:4101 W 95TH ST
Practice Address - Street 2:
Practice Address - City:OAK LAWN
Practice Address - State:IL
Practice Address - Zip Code:60453-3587
Practice Address - Country:US
Practice Address - Phone:708-715-9674
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-11
Last Update Date:2013-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051033870183500000X
FLPS19741183500000X
IN26019073A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist