Provider Demographics
NPI:1770114738
Name:KEIM, MATT
Entity type:Individual
Prefix:
First Name:MATT
Middle Name:
Last Name:KEIM
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 1:100 CHAPEL DR STE A
Mailing Address - Street 2:
Mailing Address - City:MONETT
Mailing Address - State:MO
Mailing Address - Zip Code:65708-9378
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:100 CHAPEL DR STE A
Practice Address - Street 2:
Practice Address - City:MONETT
Practice Address - State:MO
Practice Address - Zip Code:65708-9378
Practice Address - Country:US
Practice Address - Phone:417-635-1100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-29
Last Update Date:2020-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2013042216183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist