Provider Demographics
NPI:1548763139
Name:KEENE, IVA LYN (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:IVA
Middle Name:LYN
Last Name:KEENE
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 1:1137 MILDRED ST
Mailing Address - Street 2:
Mailing Address - City:FLUSHING
Mailing Address - State:MI
Mailing Address - Zip Code:48433-1757
Mailing Address - Country:US
Mailing Address - Phone:989-619-3496
Mailing Address - Fax:
Practice Address - Street 1:1565 E PIERSON RD
Practice Address - Street 2:
Practice Address - City:FLUSHING
Practice Address - State:MI
Practice Address - Zip Code:48433-1816
Practice Address - Country:US
Practice Address - Phone:810-659-2940
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-09
Last Update Date:2019-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302041913183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist