Provider Demographics
NPI:1336774207
Name:KELLER, MEGAN JOYCE
Entity Type:Individual
Prefix:
First Name:MEGAN
Middle Name:JOYCE
Last Name:KELLER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10136 YATES CT N
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55443-2231
Mailing Address - Country:US
Mailing Address - Phone:763-516-5113
Mailing Address - Fax:
Practice Address - Street 1:11990 BUSINESS PARK BLVD N
Practice Address - Street 2:
Practice Address - City:CHAMPLIN
Practice Address - State:MN
Practice Address - Zip Code:55316-2005
Practice Address - Country:US
Practice Address - Phone:763-345-1007
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-11
Last Update Date:2020-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN123363183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist