Provider Demographics
NPI:1497166458
Name:KEISLER, MARY DIANE (RPH)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:DIANE
Last Name:KEISLER
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4794 HIGHWAY 162
Mailing Address - Street 2:SUITE A
Mailing Address - City:HOLLYWOOD
Mailing Address - State:SC
Mailing Address - Zip Code:29449-5740
Mailing Address - Country:US
Mailing Address - Phone:843-769-6522
Mailing Address - Fax:843-769-5728
Practice Address - Street 1:4794 HIGHWAY 162
Practice Address - Street 2:SUITE A
Practice Address - City:HOLLYWOOD
Practice Address - State:SC
Practice Address - Zip Code:29449-5740
Practice Address - Country:US
Practice Address - Phone:843-769-6522
Practice Address - Fax:843-769-5728
Is Sole Proprietor?:No
Enumeration Date:2014-05-13
Last Update Date:2014-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC7890183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist