Healthcare Provider Details

I. General information

NPI: 1235752379
Provider Name (Legal Business Name): MR. KEITH ALAN WURTZ
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/23/2020
Last Update Date: 05/23/2020
Certification Date: 05/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1012 OKOBOJI AVE
MILFORD IA
51351-1375
US

IV. Provider business mailing address

27 AIRPORT DR
MILFORD IA
51351-8400
US

V. Phone/Fax

Practice location:
  • Phone: 712-338-4865
  • Fax: 712-338-4822
Mailing address:
  • Phone: 712-338-4048
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number15586
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: