Provider Demographics
NPI:1689275901
Name:DAVID, KEITH WAYNE (RPH)
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:WAYNE
Last Name:DAVID
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 1:1270 FOX CIR
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN VIEW
Mailing Address - State:MO
Mailing Address - Zip Code:65548-7391
Mailing Address - Country:US
Mailing Address - Phone:417-247-0271
Mailing Address - Fax:
Practice Address - Street 1:101 W US HIGHWAY 60
Practice Address - Street 2:
Practice Address - City:MOUNTAIN VIEW
Practice Address - State:MO
Practice Address - Zip Code:65548-8542
Practice Address - Country:US
Practice Address - Phone:417-934-2212
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-03
Last Update Date:2020-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO040142183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist