Healthcare Provider Details

I. General information

NPI: 1801893789
Provider Name (Legal Business Name): KEITH CHARLES GALLUS PHARMACY
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 07/07/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 MONROE ST
ANOKA MN
55303-2405
US

IV. Provider business mailing address

8436 TOLEDO AVE N
BROOKLYN PARK MN
55443-2284
US

V. Phone/Fax

Practice location:
  • Phone: 767-421-5540
  • Fax: 763-421-9229
Mailing address:
  • Phone: 763-315-1006
  • Fax: 763-421-9229

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number1177615
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: