Provider Demographics
NPI:1336786813
Name:OVERHOLT, KEITH ALLEN
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:ALLEN
Last Name:OVERHOLT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14751 N COUNTY ROAD 400 E
Mailing Address - Street 2:
Mailing Address - City:EATON
Mailing Address - State:IN
Mailing Address - Zip Code:47338-8888
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1500 W MCGALLIARD RD
Practice Address - Street 2:
Practice Address - City:MUNCIE
Practice Address - State:IN
Practice Address - Zip Code:47304-2203
Practice Address - Country:US
Practice Address - Phone:765-741-1494
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-04
Last Update Date:2019-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26024160A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist