Provider Demographics
NPI:1407564503
Name:BRILL, KEITH A
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:A
Last Name:BRILL
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 1:15091 18TH ST NE
Mailing Address - Street 2:
Mailing Address - City:LITTLE FALLS
Mailing Address - State:MN
Mailing Address - Zip Code:56345-4579
Mailing Address - Country:US
Mailing Address - Phone:320-632-3644
Mailing Address - Fax:
Practice Address - Street 1:15091 18TH ST NE
Practice Address - Street 2:
Practice Address - City:LITTLE FALLS
Practice Address - State:MN
Practice Address - Zip Code:56345-4579
Practice Address - Country:US
Practice Address - Phone:320-632-3644
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-08
Last Update Date:2022-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN125864183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist