Healthcare Provider Details

I. General information

NPI: 1144741273
Provider Name (Legal Business Name): DIANNE KEOKHAM PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/28/2017
Last Update Date: 06/28/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6632 PACIFIC AVE
STOCKTON CA
95207-3720
US

IV. Provider business mailing address

6632 PACIFIC AVE
STOCKTON CA
95207-3720
US

V. Phone/Fax

Practice location:
  • Phone: 209-951-6544
  • Fax: 209-478-8895
Mailing address:
  • Phone: 209-951-6544
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number66275
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: