Provider Demographics
NPI:1568049203
Name:MULLINS, KEITH ALLEN (EXCPT, CPHT)
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:ALLEN
Last Name:MULLINS
Suffix:
Gender:M
Credentials:EXCPT, CPHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:207 ETNA AVE
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:46750-3228
Mailing Address - Country:US
Mailing Address - Phone:260-519-0614
Mailing Address - Fax:
Practice Address - Street 1:2800 WAL MART DR
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:IN
Practice Address - Zip Code:46750-7977
Practice Address - Country:US
Practice Address - Phone:260-519-0614
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-27
Last Update Date:2021-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN67032453A183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician