Healthcare Provider Details

I. General information

NPI: 1669479507
Provider Name (Legal Business Name): JANE KIMBLE KELLER PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2005
Last Update Date: 12/09/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1120 15TH ST DEPARTMENT OF PHARMACY
AUGUSTA GA
30912-0004
US

IV. Provider business mailing address

1120 15TH ST DEPARTMENT OF PHARMACY
AUGUSTA GA
30912-0004
US

V. Phone/Fax

Practice location:
  • Phone: 706-721-4815
  • Fax:
Mailing address:
  • Phone: 706-721-4815
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P1200X
TaxonomyPharmacotherapy Pharmacist
License Number21034
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: