Provider Demographics
NPI:1811022684
Name:SERRAGO, KEITH RICHARD (RPH,PHARMD,CPH)
Entity Type:Individual
Prefix:MR
First Name:KEITH
Middle Name:RICHARD
Last Name:SERRAGO
Suffix:
Gender:M
Credentials:RPH,PHARMD,CPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1026 SW BAYSHORE BLVD
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34983-2400
Mailing Address - Country:US
Mailing Address - Phone:772-344-0409
Mailing Address - Fax:
Practice Address - Street 1:1026 SW BAYSHORE BLVD
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34983-2400
Practice Address - Country:US
Practice Address - Phone:772-344-0409
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-22
Last Update Date:2013-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS18542183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL101097200Medicaid
FL1294300001Medicare PIN