Healthcare Provider Details

I. General information

NPI: 1801188255
Provider Name (Legal Business Name): KEITH DAVID WILEY R.PH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/04/2011
Last Update Date: 05/04/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

230 S MAIN ST
BELLEFONTAINE OH
43311-1702
US

IV. Provider business mailing address

230 S MAIN ST
BELLEFONTAINE OH
43311-1702
US

V. Phone/Fax

Practice location:
  • Phone: 937-599-2314
  • Fax: 937-599-2320
Mailing address:
  • Phone: 937-599-2314
  • Fax: 937-599-2320

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number03-1-12295
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: