Provider Demographics
NPI:1467738294
Name:BREYER, KEITH NICHOLAS (PHARM D)
Entity Type:Individual
Prefix:DR
First Name:KEITH
Middle Name:NICHOLAS
Last Name:BREYER
Suffix:
Gender:M
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:612 PARK ST
Mailing Address - Street 2:
Mailing Address - City:ALTURAS
Mailing Address - State:CA
Mailing Address - Zip Code:96101-3844
Mailing Address - Country:US
Mailing Address - Phone:702-217-5991
Mailing Address - Fax:
Practice Address - Street 1:432 N MAIN ST
Practice Address - Street 2:
Practice Address - City:ALTURAS
Practice Address - State:CA
Practice Address - Zip Code:96101-3458
Practice Address - Country:US
Practice Address - Phone:530-233-3113
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-25
Last Update Date:2011-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORRPH-0012860183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist