Provider Demographics
NPI:1720378045
Name:HAZELY, KEITH DARREL SR (PHARMACIST)
Entity Type:Individual
Prefix:MR
First Name:KEITH
Middle Name:DARREL
Last Name:HAZELY
Suffix:SR
Gender:M
Credentials:PHARMACIST
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:13701 VAN DYKE SUITE 190
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48093-7951
Mailing Address - Country:US
Mailing Address - Phone:586-276-8040
Mailing Address - Fax:586-276-8039
Practice Address - Street 1:31700 VAN DYKE AVE STE 190
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48093-7951
Practice Address - Country:US
Practice Address - Phone:586-276-8040
Practice Address - Fax:586-276-8039
Is Sole Proprietor?:No
Enumeration Date:2011-04-08
Last Update Date:2011-04-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI5302024376183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist