Provider Demographics
NPI:1164855169
Name:MCWILLIAMS, KEITH JEROME (RPH)
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:JEROME
Last Name:MCWILLIAMS
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 1:1200 DODSON AVE
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37406-3214
Mailing Address - Country:US
Mailing Address - Phone:423-386-1107
Mailing Address - Fax:423-698-8288
Practice Address - Street 1:1200 DODSON AVE
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37406-3214
Practice Address - Country:US
Practice Address - Phone:423-386-1107
Practice Address - Fax:423-698-8288
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-13
Last Update Date:2013-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN011335183500000X
GARPH014334183500000X
AL10572183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist