Provider Demographics
NPI:1194972323
Name:PEARSON, KEITH CONRAD (RPH)
Entity type:Individual
Prefix:MR
First Name:KEITH
Middle Name:CONRAD
Last Name:PEARSON
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 258
Mailing Address - Street 2:
Mailing Address - City:BIGFORK
Mailing Address - State:MN
Mailing Address - Zip Code:56628-0258
Mailing Address - Country:US
Mailing Address - Phone:218-743-4444
Mailing Address - Fax:218-743-4232
Practice Address - Street 1:258 PINETREE DRIVE
Practice Address - Street 2:
Practice Address - City:BIGFORK
Practice Address - State:MN
Practice Address - Zip Code:56628-0258
Practice Address - Country:US
Practice Address - Phone:218-743-4444
Practice Address - Fax:218-743-4232
Is Sole Proprietor?:No
Enumeration Date:2008-08-19
Last Update Date:2008-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN112141183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist