Provider Demographics
NPI:1194980839
Name:FISHER, KELTON STEWART JR (DPH)
Entity type:Individual
Prefix:DR
First Name:KELTON
Middle Name:STEWART
Last Name:FISHER
Suffix:JR
Gender:M
Credentials:DPH
Other - Prefix:DR
Other - First Name:KELTON
Other - Middle Name:STEWART
Other - Last Name:FISHER
Other - Suffix:JR
Other - Last Name Type:Professional Name
Other - Credentials:DPH
Mailing Address - Street 1:1396 HATCHER LN
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:TN
Mailing Address - Zip Code:38401-3568
Mailing Address - Country:US
Mailing Address - Phone:931-381-1395
Mailing Address - Fax:931-388-6771
Practice Address - Street 1:1396 HATCHER LN
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:TN
Practice Address - Zip Code:38401-3568
Practice Address - Country:US
Practice Address - Phone:931-381-1395
Practice Address - Fax:931-388-6771
Is Sole Proprietor?:No
Enumeration Date:2008-07-22
Last Update Date:2008-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN256183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist