Provider Demographics
NPI:1952632572
Name:PERSICKE, KEITH (PHAMD)
Entity Type:Individual
Prefix:MR
First Name:KEITH
Middle Name:
Last Name:PERSICKE
Suffix:
Gender:M
Credentials:PHAMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21200 E COUNTRY VISTA DR
Mailing Address - Street 2:J101
Mailing Address - City:LIBERTY LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:99019-7636
Mailing Address - Country:US
Mailing Address - Phone:406-240-1313
Mailing Address - Fax:
Practice Address - Street 1:15510 E SPRAGUE AVE
Practice Address - Street 2:
Practice Address - City:SPOKANE VALLEY
Practice Address - State:WA
Practice Address - Zip Code:99037-8945
Practice Address - Country:US
Practice Address - Phone:509-891-0735
Practice Address - Fax:509-891-4082
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-21
Last Update Date:2010-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH00049819183500000X
MTMT4525183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist