Provider Demographics
NPI:1508995994
Name:VAN HEISE, KEITH FREAL (PHARM D)
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:FREAL
Last Name:VAN HEISE
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 1:12906 W WILSHIRE DR
Mailing Address - Street 2:
Mailing Address - City:AVONDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85323-7134
Mailing Address - Country:US
Mailing Address - Phone:602-740-6984
Mailing Address - Fax:
Practice Address - Street 1:12906 W WILSHIRE DR
Practice Address - Street 2:
Practice Address - City:AVONDALE
Practice Address - State:AZ
Practice Address - Zip Code:85323-7134
Practice Address - Country:US
Practice Address - Phone:602-740-6984
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ13731183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist