Healthcare Provider Details

I. General information

NPI: 1689659856
Provider Name (Legal Business Name): GREGORY STUART KEITH PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/10/2005
Last Update Date: 11/02/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2449 W KETTLEMAN LANE
LODI CA
95242
US

IV. Provider business mailing address

PO BOX 1623
WOODBRIDGE CA
95258-1623
US

V. Phone/Fax

Practice location:
  • Phone: 209-367-7882
  • Fax: 209-367-7886
Mailing address:
  • Phone: 209-334-4908
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberRPH39476
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: