MEDICARE: KEITH THOMAS WALSH PHARM.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	S019853	AZ
2	1835P0018X	Pharmacist Clinician (PhC)/ Clinical Pharmacy Specialist	S019853	AZ

General Provider Information

NPI Number	:	1295160521
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KEITH THOMAS WALSH PHARM.D.

Provider Business Mailing Address
First Line	:	4747 S HIGHWAY 95
Second Line	:
City	:	FORT MOHAVE
State	:	AZ
Zip	:	86426-9377
Country	:	US
Telephone Number	:	928-330-3704
Fax Number	:	928-330-3707

Provider Business Practice Location Address
First Line	:	4747 S HIGHWAY 95
Second Line	:
City	:	FORT MOHAVE
State	:	AZ
Zip	:	86426-9377
Country	:	US
Telephone Number	:	928-330-3704
Fax Number	:	928-330-3707

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/05/2013
Last Update Date	:	10/25/2020

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