Provider Demographics
NPI:1780678060
Name:MCKINNISS, KEITH A (RPH)
Entity Type:Individual
Prefix:MR
First Name:KEITH
Middle Name:A
Last Name:MCKINNISS
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 1:30381 CHIEFTAIN DR
Mailing Address - Street 2:
Mailing Address - City:LOGAN
Mailing Address - State:OH
Mailing Address - Zip Code:43138-9092
Mailing Address - Country:US
Mailing Address - Phone:740-385-3120
Mailing Address - Fax:
Practice Address - Street 1:30381 CHIEFTAIN DR
Practice Address - Street 2:
Practice Address - City:LOGAN
Practice Address - State:OH
Practice Address - Zip Code:43138-9092
Practice Address - Country:US
Practice Address - Phone:740-385-3120
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-01
Last Update Date:2021-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03124661183500000X
OH03-1-24661183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist