Provider Demographics
NPI:1700161296
Name:RUBRUM, KEITH D (DPH)
Entity Type:Individual
Prefix:DR
First Name:KEITH
Middle Name:D
Last Name:RUBRUM
Suffix:
Gender:M
Credentials:DPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4155 HWY 61 SOUTH
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38109
Mailing Address - Country:US
Mailing Address - Phone:901-785-1165
Mailing Address - Fax:901-785-1165
Practice Address - Street 1:4155 HWY 61 S
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38109
Practice Address - Country:US
Practice Address - Phone:901-785-1165
Practice Address - Fax:901-785-1165
Is Sole Proprietor?:No
Enumeration Date:2011-10-15
Last Update Date:2011-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN5672183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist