Provider Demographics
NPI:1871001248
Name:KESITILWE, EZEKIEL KEERENG (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:EZEKIEL
Middle Name:KEERENG
Last Name:KESITILWE
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 1:2734 PASEO VERDE
Mailing Address - Street 2:
Mailing Address - City:LAKE HAVASU CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86406-7748
Mailing Address - Country:US
Mailing Address - Phone:928-230-9812
Mailing Address - Fax:
Practice Address - Street 1:1980 MCCULLOCH BLVD N
Practice Address - Street 2:
Practice Address - City:LAKE HAVASU CITY
Practice Address - State:AZ
Practice Address - Zip Code:86403-0969
Practice Address - Country:US
Practice Address - Phone:928-854-8281
Practice Address - Fax:928-453-3969
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-18
Last Update Date:2018-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZS013695333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy