Provider Demographics
NPI:1689987414
Name:KEITH, KELLY (PHARMD)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:KEITH
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:
Other - Last Name:ACKERMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHARMD
Mailing Address - Street 1:500 JOHN DEERE RD
Mailing Address - Street 2:
Mailing Address - City:MOLINE
Mailing Address - State:IL
Mailing Address - Zip Code:61265-6892
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:500 JOHN DEERE RD
Practice Address - Street 2:
Practice Address - City:MOLINE
Practice Address - State:IL
Practice Address - Zip Code:61265-6892
Practice Address - Country:US
Practice Address - Phone:309-779-5038
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-07-21
Last Update Date:2014-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA21242183500000X
IL051294681183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist