Healthcare Provider Details

I. General information

NPI: 1639629827
Provider Name (Legal Business Name): KEITH DONG PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/11/2016
Last Update Date: 10/11/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2222 BANCROFT WAY PHARMACY; RM 1115
BERKELEY CA
94720-4301
US

IV. Provider business mailing address

2222 BANCROFT WAY PHARMACY; RM 1115
BERKELEY CA
94720-4301
US

V. Phone/Fax

Practice location:
  • Phone: 510-642-3249
  • Fax: 510-642-5759
Mailing address:
  • Phone: 510-642-3249
  • Fax: 510-642-5759

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License Number38042
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: