Provider Demographics
NPI:1316263973
Name:RUBOTTOM, KEITH ALLEN (PHARMD)
Entity type:Individual
Prefix:DR
First Name:KEITH
Middle Name:ALLEN
Last Name:RUBOTTOM
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 1:1328 STADIUM BLVD
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72401-4578
Mailing Address - Country:US
Mailing Address - Phone:870-935-2532
Mailing Address - Fax:
Practice Address - Street 1:1328 STADIUM BLVD
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:AR
Practice Address - Zip Code:72401-4578
Practice Address - Country:US
Practice Address - Phone:870-935-2532
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-04-07
Last Update Date:2010-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPD09142183500000X
TN0000033412183500000X
MO2007025915183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist