Healthcare Provider Details

I. General information

NPI: 1639468333
Provider Name (Legal Business Name): KEITH M CARSON PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

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

III. Provider practice location address

500 N MAIN AVE
SCRANTON PA
18504-1866
US

IV. Provider business mailing address

211 SWINNICK DR
DUNMORE PA
18512-2072
US

V. Phone/Fax

Practice location:
  • Phone: 570-342-6411
  • Fax:
Mailing address:
  • Phone: 570-941-9440
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberRP439688
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
IdentifierRP439688
Identifier TypeOTHER
Identifier StatePA
Identifier IssuerSTATE LISCENSE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: