Provider Demographics
NPI:1336436294
Name:MIHAVICS, KEELY RENEE (PHARMD)
Entity type:Individual
Prefix:DR
First Name:KEELY
Middle Name:RENEE
Last Name:MIHAVICS
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:303 N WILLOW RD
Mailing Address - Street 2:
Mailing Address - City:ELMHURST
Mailing Address - State:IL
Mailing Address - Zip Code:60126-2453
Mailing Address - Country:US
Mailing Address - Phone:630-673-0048
Mailing Address - Fax:
Practice Address - Street 1:5001 N BIG HOLLOW RD
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61615-3538
Practice Address - Country:US
Practice Address - Phone:630-673-0048
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-29
Last Update Date:2011-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051.294951183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist