Provider Demographics
NPI:1952317398
Name:KEENE, GEORGE RANDALL (RPH)
Entity Type:Individual
Prefix:
First Name:GEORGE
Middle Name:RANDALL
Last Name:KEENE
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 1:114 N VALHALLA CT
Mailing Address - Street 2:
Mailing Address - City:CORDELE
Mailing Address - State:GA
Mailing Address - Zip Code:31015-9308
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:298 MEDICAL CT
Practice Address - Street 2:
Practice Address - City:OGLETHORPE
Practice Address - State:GA
Practice Address - Zip Code:31068
Practice Address - Country:US
Practice Address - Phone:478-472-2040
Practice Address - Fax:478-472-9822
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA012172183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist