Provider Demographics
NPI:1902409345
Name:SMITH, KEITH LETISTE (PHARMD)
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:LETISTE
Last Name:SMITH
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:39 CAMELLIA LN
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:MS
Mailing Address - Zip Code:39110-9348
Mailing Address - Country:US
Mailing Address - Phone:601-260-1034
Mailing Address - Fax:
Practice Address - Street 1:127 GRANDVIEW BLVD
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:MS
Practice Address - Zip Code:39110-7595
Practice Address - Country:US
Practice Address - Phone:601-605-9615
Practice Address - Fax:601-605-9678
Is Sole Proprietor?:No
Enumeration Date:2020-11-18
Last Update Date:2020-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS09250183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist