Provider Demographics
NPI:1265031595
Name:HEROLD, KEITH WAYNE
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:WAYNE
Last Name:HEROLD
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 1:2080 SWEETFERN DR
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54313-4366
Mailing Address - Country:US
Mailing Address - Phone:920-676-6422
Mailing Address - Fax:
Practice Address - Street 1:2440 W MASON ST
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54303-4711
Practice Address - Country:US
Practice Address - Phone:920-499-2330
Practice Address - Fax:920-499-1136
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-19
Last Update Date:2020-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI12269-040183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist