Provider Demographics
NPI:1063563138
Name:KELLER, JOHN L (RPH)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:L
Last Name:KELLER
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 669
Mailing Address - Street 2:
Mailing Address - City:ROLLA
Mailing Address - State:MO
Mailing Address - Zip Code:65402-0669
Mailing Address - Country:US
Mailing Address - Phone:573-364-6886
Mailing Address - Fax:
Practice Address - Street 1:500 HWY 72ND WEST ROLLA
Practice Address - Street 2:HILLCREST SHOPPING CTR
Practice Address - City:ROLLA
Practice Address - State:MO
Practice Address - Zip Code:65401
Practice Address - Country:US
Practice Address - Phone:573-364-3258
Practice Address - Fax:573-341-2540
Is Sole Proprietor?:No
Enumeration Date:2007-01-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO027453183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist