Provider Demographics
NPI:1497703011
Name:GAEDE, KEITH ALAN (RPH)
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:ALAN
Last Name:GAEDE
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8992 PENINSULA DR
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49686-1561
Mailing Address - Country:US
Mailing Address - Phone:231-995-0961
Mailing Address - Fax:
Practice Address - Street 1:6404 WESTERN AVE
Practice Address - Street 2:
Practice Address - City:GLEN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:49636
Practice Address - Country:US
Practice Address - Phone:231-334-6608
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302021381183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist