Provider Demographics
NPI:1033450259
Name:WILEY, KEITH MICHAEL (RPH)
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:MICHAEL
Last Name:WILEY
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:725 E VILLA MARIA RD
Mailing Address - Street 2:
Mailing Address - City:BRYAN
Mailing Address - State:TX
Mailing Address - Zip Code:77802-5319
Mailing Address - Country:US
Mailing Address - Phone:979-822-1850
Mailing Address - Fax:979-775-6872
Practice Address - Street 1:725 E VILLA MARIA RD
Practice Address - Street 2:
Practice Address - City:BRYAN
Practice Address - State:TX
Practice Address - Zip Code:77802-5319
Practice Address - Country:US
Practice Address - Phone:979-822-1850
Practice Address - Fax:979-775-6872
Is Sole Proprietor?:No
Enumeration Date:2013-03-13
Last Update Date:2013-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX37826183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist