MEDICARE: DR. KEISHA ROLLINS MINGO PHARMD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101Y00000X	Counselor

General Provider Information

NPI Number	:	1124623053
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KEISHA ROLLINS MINGO PHARMD

Provider Business Mailing Address
First Line	:	3920 LINDEN AVE
Second Line	:
City	:	DAYTON
State	:	OH
Zip	:	45432-3004
Country	:	US
Telephone Number	:	937-254-6165
Fax Number	:	937-254-6165

Provider Business Practice Location Address
First Line	:	3920 LINDEN AVE
Second Line	:
City	:	DAYTON
State	:	OH
Zip	:	45432-3004
Country	:	US
Telephone Number	:	937-254-6165
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/30/2020
Last Update Date	:	11/30/2020

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