Provider Demographics
NPI:1730275892
Name:KELLER, MICHAEL L (RPH, PHARMD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:L
Last Name:KELLER
Suffix:
Gender:M
Credentials:RPH, PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 498
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:KY
Mailing Address - Zip Code:42078-0498
Mailing Address - Country:US
Mailing Address - Phone:270-988-3230
Mailing Address - Fax:270-988-4230
Practice Address - Street 1:141 HOSPITAL DRIVE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:KY
Practice Address - Zip Code:42078
Practice Address - Country:US
Practice Address - Phone:270-988-3230
Practice Address - Fax:270-988-4230
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-05
Last Update Date:2010-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY007739183500000X, 1835N1003X, 1835P1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
No1835N1003XPharmacy Service ProvidersPharmacistNutrition Support
No1835P1200XPharmacy Service ProvidersPharmacistPharmacotherapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY007739OtherPHARMACIST LICENSE