Provider Demographics
NPI:1801185905
Name:CLARKE, KEITH WEATHERS (RPH)
Entity Type:Individual
Prefix:MR
First Name:KEITH
Middle Name:WEATHERS
Last Name:CLARKE
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 1:3120 POLO PKWY
Mailing Address - Street 2:
Mailing Address - City:MIDLOTHIAN
Mailing Address - State:VA
Mailing Address - Zip Code:23113-4822
Mailing Address - Country:US
Mailing Address - Phone:804-594-3791
Mailing Address - Fax:804-594-0852
Practice Address - Street 1:3120 POLO PKWY
Practice Address - Street 2:
Practice Address - City:MIDLOTHIAN
Practice Address - State:VA
Practice Address - Zip Code:23113-4822
Practice Address - Country:US
Practice Address - Phone:804-594-3791
Practice Address - Fax:804-594-0852
Is Sole Proprietor?:No
Enumeration Date:2011-03-30
Last Update Date:2011-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202004517183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist