Provider Demographics
NPI:1588216766
Name:KELLER, JACOB (PHARMD)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:KELLER
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:99 EDISON BLVD STE L
Mailing Address - Street 2:
Mailing Address - City:SILVER BAY
Mailing Address - State:MN
Mailing Address - Zip Code:55614-1269
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:99 EDISON BLVD STE L
Practice Address - Street 2:
Practice Address - City:SILVER BAY
Practice Address - State:MN
Practice Address - Zip Code:55614-1269
Practice Address - Country:US
Practice Address - Phone:218-226-3829
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-09
Last Update Date:2019-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN124260183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist