Provider Demographics
NPI:1497035034
Name:KEELE, THOMAS M
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:M
Last Name:KEELE
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 1:999 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LOGAN
Mailing Address - State:UT
Mailing Address - Zip Code:84321-3230
Mailing Address - Country:US
Mailing Address - Phone:435-227-1100
Mailing Address - Fax:435-227-1106
Practice Address - Street 1:999 N MAIN ST
Practice Address - Street 2:
Practice Address - City:LOGAN
Practice Address - State:UT
Practice Address - Zip Code:84321-3230
Practice Address - Country:US
Practice Address - Phone:435-227-1100
Practice Address - Fax:435-227-1106
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-26
Last Update Date:2011-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT4992510-1701183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist