Healthcare Provider Details

I. General information

NPI: 1063563138
Provider Name (Legal Business Name): JOHN L KELLER RPH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/16/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 HWY 72ND WEST ROLLA HILLCREST SHOPPING CTR
ROLLA MO
65401
US

IV. Provider business mailing address

PO BOX 669
ROLLA MO
65402-0669
US

V. Phone/Fax

Practice location:
  • Phone: 573-364-3258
  • Fax: 573-341-2540
Mailing address:
  • Phone: 573-364-6886
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number027453
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: