Provider Demographics
NPI:1467630459
Name:NELSON, KEITH ALAN (PHARMACIST)
Entity Type:Individual
Prefix:MR
First Name:KEITH
Middle Name:ALAN
Last Name:NELSON
Suffix:
Gender:M
Credentials:PHARMACIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:626 GRAY FOX RD
Mailing Address - Street 2:
Mailing Address - City:BLUE EYE
Mailing Address - State:MO
Mailing Address - Zip Code:65611-8149
Mailing Address - Country:US
Mailing Address - Phone:417-779-3008
Mailing Address - Fax:417-779-3008
Practice Address - Street 1:626 GRAY FOX RD
Practice Address - Street 2:
Practice Address - City:BLUE EYE
Practice Address - State:MO
Practice Address - Zip Code:65611-8149
Practice Address - Country:US
Practice Address - Phone:417-779-3008
Practice Address - Fax:417-779-3008
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-01
Last Update Date:2014-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO28997183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist