Provider Demographics
NPI:1376146118
Name:KERYESKI, MICHAEL GARRET
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:GARRET
Last Name:KERYESKI
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 1:161 JACOBS CT
Mailing Address - Street 2:
Mailing Address - City:LOVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:45140-8547
Mailing Address - Country:US
Mailing Address - Phone:724-681-9815
Mailing Address - Fax:
Practice Address - Street 1:9525 KENWOOD RD STE 1
Practice Address - Street 2:
Practice Address - City:BLUE ASH
Practice Address - State:OH
Practice Address - Zip Code:45242-6177
Practice Address - Country:US
Practice Address - Phone:513-793-7171
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-16
Last Update Date:2020-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH1003693183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist