Healthcare Provider Details

I. General information

NPI: 1518268234
Provider Name (Legal Business Name): KEITH DAUGHERTY RPH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/11/2010
Last Update Date: 04/11/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20120 PINEBROOK BLVD
BEND OR
97702-2537
US

IV. Provider business mailing address

60951 SE SWEET PEA DR
BEND OR
97702-9759
US

V. Phone/Fax

Practice location:
  • Phone: 541-389-5440
  • Fax:
Mailing address:
  • Phone: 541-912-1245
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License Number7178
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number7178
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: