Provider Demographics
NPI:1457628547
Name:PAGE, KEITH (PHARMD)
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:
Last Name:PAGE
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2622 W 11275 S
Mailing Address - Street 2:
Mailing Address - City:SOUTH JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84095-8377
Mailing Address - Country:US
Mailing Address - Phone:801-256-0376
Mailing Address - Fax:
Practice Address - Street 1:2622 W 11275 S
Practice Address - Street 2:
Practice Address - City:SOUTH JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84095-8377
Practice Address - Country:US
Practice Address - Phone:801-256-0376
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-11-17
Last Update Date:2011-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6374809183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist