Provider Demographics
NPI:1124632591
Name:KEITH, LAUREN JO
Entity type:Individual
Prefix:
First Name:LAUREN
Middle Name:JO
Last Name:KEITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1445 SOUTH MAIN STREET
Mailing Address - Street 2:PHARMACY MANAGER
Mailing Address - City:OTTAWA
Mailing Address - State:KS
Mailing Address - Zip Code:66067
Mailing Address - Country:US
Mailing Address - Phone:785-242-4745
Mailing Address - Fax:785-242-5023
Practice Address - Street 1:1445 S MAIN ST
Practice Address - Street 2:
Practice Address - City:OTTAWA
Practice Address - State:KS
Practice Address - Zip Code:66067-3528
Practice Address - Country:US
Practice Address - Phone:785-242-4745
Practice Address - Fax:785-242-5023
Is Sole Proprietor?:No
Enumeration Date:2020-09-03
Last Update Date:2020-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1-109366183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist