Provider Demographics
NPI:1235752379
Name:WURTZ, KEITH ALAN
Entity Type:Individual
Prefix:MR
First Name:KEITH
Middle Name:ALAN
Last Name:WURTZ
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 1:27 AIRPORT DR
Mailing Address - Street 2:
Mailing Address - City:MILFORD
Mailing Address - State:IA
Mailing Address - Zip Code:51351-8400
Mailing Address - Country:US
Mailing Address - Phone:712-338-4048
Mailing Address - Fax:
Practice Address - Street 1:1012 OKOBOJI AVE
Practice Address - Street 2:
Practice Address - City:MILFORD
Practice Address - State:IA
Practice Address - Zip Code:51351-1375
Practice Address - Country:US
Practice Address - Phone:712-338-4865
Practice Address - Fax:712-338-4822
Is Sole Proprietor?:No
Enumeration Date:2020-05-23
Last Update Date:2020-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA15586183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist