Provider Demographics
NPI:1508292731
Name:KELLER, EIZABETH A (PHARMD)
Entity Type:Individual
Prefix:
First Name:EIZABETH
Middle Name:A
Last Name:KELLER
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:708 EAST SELTICE WAY
Mailing Address - Street 2:
Mailing Address - City:POST FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83854
Mailing Address - Country:US
Mailing Address - Phone:208-777-4071
Mailing Address - Fax:208-773-0913
Practice Address - Street 1:708 EAST SELTICE WAY
Practice Address - Street 2:
Practice Address - City:POST FALLS
Practice Address - State:ID
Practice Address - Zip Code:83854
Practice Address - Country:US
Practice Address - Phone:208-777-4071
Practice Address - Fax:208-773-0913
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-19
Last Update Date:2013-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH00055898183500000X
CO18591183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO18591OtherLICENSE
WAPH00055898OtherLICENSE