Provider Demographics
NPI:1982218525
Name:FUENTES, KEITH R (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:KEITH
Middle Name:R
Last Name:FUENTES
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 1:221 N WESTERN AVE
Mailing Address - Street 2:
Mailing Address - City:WEST PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61604-5640
Mailing Address - Country:US
Mailing Address - Phone:309-673-0665
Mailing Address - Fax:309-673-3593
Practice Address - Street 1:221 N WESTERN AVE
Practice Address - Street 2:
Practice Address - City:WEST PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61604-5640
Practice Address - Country:US
Practice Address - Phone:309-673-0665
Practice Address - Fax:309-673-3593
Is Sole Proprietor?:No
Enumeration Date:2020-09-01
Last Update Date:2020-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051299712183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist