Provider Demographics
NPI:1285972810
Name:KEOVILAY, SIVILAY
Entity type:Individual
Prefix:
First Name:SIVILAY
Middle Name:
Last Name:KEOVILAY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9005 US HIGHWAY 301 N
Mailing Address - Street 2:
Mailing Address - City:PARRISH
Mailing Address - State:FL
Mailing Address - Zip Code:34219-8673
Mailing Address - Country:US
Mailing Address - Phone:941-776-3413
Mailing Address - Fax:
Practice Address - Street 1:9005 US HIGHWAY 301 N
Practice Address - Street 2:
Practice Address - City:PARRISH
Practice Address - State:FL
Practice Address - Zip Code:34219-8673
Practice Address - Country:US
Practice Address - Phone:941-776-3413
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-01-16
Last Update Date:2013-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS36301183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist