Provider Demographics
NPI:1881642726
Name:KELLICK, KENNETH A (PHARMD)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:A
Last Name:KELLICK
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
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Mailing Address - Street 1:11 ROCHELLE PARK
Mailing Address - Street 2:
Mailing Address - City:TONAWANDA
Mailing Address - State:NY
Mailing Address - Zip Code:14150-9311
Mailing Address - Country:US
Mailing Address - Phone:716-836-1071
Mailing Address - Fax:716-862-9421
Practice Address - Street 1:3495 BAILEY AVE
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14215-1129
Practice Address - Country:US
Practice Address - Phone:716-862-6335
Practice Address - Fax:716-962-6599
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY27493-11835P1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P1200XPharmacy Service ProvidersPharmacistPharmacotherapy