Healthcare Provider Details

I. General information

NPI: 1326705187
Provider Name (Legal Business Name): KEITH OKOLO PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/29/2021
Last Update Date: 11/29/2021
Certification Date: 11/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

910 ATHENS HWY
LOGANVILLE GA
30052-4952
US

IV. Provider business mailing address

2521 PIEDMONT RD NE APT 2024
ATLANTA GA
30324-6264
US

V. Phone/Fax

Practice location:
  • Phone: 770-554-1111
  • Fax:
Mailing address:
  • Phone: 215-833-2217
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberRPH033419
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: