Provider Demographics
NPI:1861046021
Name:PECK, KELTON D (PHARMD)
Entity Type:Individual
Prefix:
First Name:KELTON
Middle Name:D
Last Name:PECK
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2601 SCOFIELD RIDGE PKWY APT 317
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78727-6342
Mailing Address - Country:US
Mailing Address - Phone:208-206-8607
Mailing Address - Fax:
Practice Address - Street 1:12860 RESEARCH BLVD
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78750-3222
Practice Address - Country:US
Practice Address - Phone:512-506-9060
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-26
Last Update Date:2019-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX65033183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist