Provider Demographics
NPI:1386632891
Name:HENTZEN, KEITH RONALD (RP)
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:RONALD
Last Name:HENTZEN
Suffix:
Gender:M
Credentials:RP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18907 WALNUT DR
Mailing Address - Street 2:
Mailing Address - City:GRETNA
Mailing Address - State:NE
Mailing Address - Zip Code:68028-7238
Mailing Address - Country:US
Mailing Address - Phone:402-332-4668
Mailing Address - Fax:
Practice Address - Street 1:205 MAIN ST
Practice Address - Street 2:#130
Practice Address - City:SPRINGFIELD
Practice Address - State:NE
Practice Address - Zip Code:68059-3230
Practice Address - Country:US
Practice Address - Phone:402-253-2000
Practice Address - Fax:402-253-2001
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-10
Last Update Date:2016-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE8552183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist