Provider Demographics
NPI:1083617187
Name:HERIST, KEITH N (PHARMD)
Entity type:Individual
Prefix:DR
First Name:KEITH
Middle Name:N
Last Name:HERIST
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 SUNSET DR
Mailing Address - Street 2:STE 102
Mailing Address - City:ATHENS
Mailing Address - State:GA
Mailing Address - Zip Code:30606-2287
Mailing Address - Country:US
Mailing Address - Phone:706-369-0301
Mailing Address - Fax:
Practice Address - Street 1:700 SUNSET DR
Practice Address - Street 2:STE 102
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30606-2287
Practice Address - Country:US
Practice Address - Phone:706-369-0301
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-05-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH018938183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist