Provider Demographics
NPI:1295160521
Name:WALSH, KEITH THOMAS (PHARMD)
Entity type:Individual
Prefix:
First Name:KEITH
Middle Name:THOMAS
Last Name:WALSH
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 1:4747 S HIGHWAY 95
Mailing Address - Street 2:
Mailing Address - City:FORT MOHAVE
Mailing Address - State:AZ
Mailing Address - Zip Code:86426-9377
Mailing Address - Country:US
Mailing Address - Phone:928-330-3704
Mailing Address - Fax:928-330-3707
Practice Address - Street 1:4747 S HIGHWAY 95
Practice Address - Street 2:
Practice Address - City:FORT MOHAVE
Practice Address - State:AZ
Practice Address - Zip Code:86426-9377
Practice Address - Country:US
Practice Address - Phone:928-330-3704
Practice Address - Fax:928-330-3707
Is Sole Proprietor?:No
Enumeration Date:2013-09-05
Last Update Date:2020-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZS019853183500000X, 1835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
No183500000XPharmacy Service ProvidersPharmacist