Provider Demographics
NPI:1538852090
Name:SUDDETH, KEIFFER PAUL (PHARMD)
Entity type:Individual
Prefix:
First Name:KEIFFER
Middle Name:PAUL
Last Name:SUDDETH
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 1:10035 NORTHBROOK VALLEY DR APT 1
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46825-2380
Mailing Address - Country:US
Mailing Address - Phone:317-440-2916
Mailing Address - Fax:
Practice Address - Street 1:907 LINCOLN HWY W
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:IN
Practice Address - Zip Code:46774-2141
Practice Address - Country:US
Practice Address - Phone:260-493-3736
Practice Address - Fax:260-749-7947
Is Sole Proprietor?:No
Enumeration Date:2023-05-31
Last Update Date:2023-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN45020981A390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program