Provider Demographics
NPI:1275815334
Name:MEDI-HEALTH PHARMACY GROUP LLC
Entity Type:Organization
Organization Name:MEDI-HEALTH PHARMACY GROUP LLC
Other - Org Name:KELLER PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST-IN-CHARGE
Authorized Official - Prefix:
Authorized Official - First Name:NIRAV
Authorized Official - Middle Name:
Authorized Official - Last Name:PATEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:973-698-0143
Mailing Address - Street 1:1200 KELLER PKWY
Mailing Address - Street 2:SUITE 200
Mailing Address - City:KELLER
Mailing Address - State:TX
Mailing Address - Zip Code:76248-3615
Mailing Address - Country:US
Mailing Address - Phone:682-593-0461
Mailing Address - Fax:682-593-0460
Practice Address - Street 1:1200 KELLER PKWY STE 200
Practice Address - Street 2:
Practice Address - City:KELLER
Practice Address - State:TX
Practice Address - Zip Code:76248-3615
Practice Address - Country:US
Practice Address - Phone:682-593-0461
Practice Address - Fax:682-593-0460
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-14
Last Update Date:2011-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
TX276423336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
5904049OtherNCPDP PROVIDER IDENTIFICATION NUMBER