Provider Demographics
NPI:1215410188
Name:KEELER, BARRY LYNN
Entity Type:Individual
Prefix:
First Name:BARRY
Middle Name:LYNN
Last Name:KEELER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3096 W LEDYARD WAY
Mailing Address - Street 2:
Mailing Address - City:APTOS
Mailing Address - State:CA
Mailing Address - Zip Code:95003-3829
Mailing Address - Country:US
Mailing Address - Phone:831-234-0322
Mailing Address - Fax:
Practice Address - Street 1:DOMINICAN PLAZA PHARMACY
Practice Address - Street 2:1595 SOQUEL DR SUITE 120
Practice Address - City:SANTA CRUZ
Practice Address - State:CA
Practice Address - Zip Code:95065
Practice Address - Country:US
Practice Address - Phone:831-462-7726
Practice Address - Fax:831-462-7615
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-07
Last Update Date:2018-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA294161835P2201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P2201XPharmacy Service ProvidersPharmacistAmbulatory Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA29416OtherCALIFORNIA STATE BOARD OF PHARMACY