Provider Demographics
NPI:1629611934
Name:SIMMONS, KEITH T
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:T
Last Name:SIMMONS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:745 FOUNTAIN GATE
Mailing Address - Street 2:
Mailing Address - City:CIBOLO
Mailing Address - State:TX
Mailing Address - Zip Code:78108-3438
Mailing Address - Country:US
Mailing Address - Phone:210-643-7391
Mailing Address - Fax:
Practice Address - Street 1:745 FOUNTAIN GATE
Practice Address - Street 2:
Practice Address - City:CIBOLO
Practice Address - State:TX
Practice Address - Zip Code:78108-3438
Practice Address - Country:US
Practice Address - Phone:210-643-7391
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-21
Last Update Date:2019-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX58668183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist