=====================================================
General NPI Number Information
=====================================================
NPI Number | 1740412667
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KEITH ALAN VANCE PHARM.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/11/2009
-----------------------------------------------------
Last Update Date | 04/09/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6715 SHALLOWFORD RD
-----------------------------------------------------
City | LEWISVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27023-9847
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 336-946-0220
-----------------------------------------------------
Fax | 336-946-0199
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6715 SHALLOWFORD ROAD
-----------------------------------------------------
City | LEWISVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27023-8258
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 336-946-0220
-----------------------------------------------------
Fax | 336-946-0199
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 16411
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------