Provider Demographics
NPI:1518268234
Name:DAUGHERTY, KEITH (RPH)
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:
Last Name:DAUGHERTY
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 1:60951 SE SWEET PEA DR
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97702-9759
Mailing Address - Country:US
Mailing Address - Phone:541-912-1245
Mailing Address - Fax:
Practice Address - Street 1:20120 PINEBROOK BLVD
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97702-2537
Practice Address - Country:US
Practice Address - Phone:541-389-5440
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-11-11
Last Update Date:2018-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR71781835P0018X, 183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
No1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist