Provider Demographics
NPI:1699058834
Name:KEISTER, LAURA ELLEN (RPH)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:ELLEN
Last Name:KEISTER
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2866 S 650 E
Mailing Address - Street 2:
Mailing Address - City:AVILLA
Mailing Address - State:IN
Mailing Address - Zip Code:46710-9723
Mailing Address - Country:US
Mailing Address - Phone:260-693-6472
Mailing Address - Fax:
Practice Address - Street 1:907 LINCOLN HWY W
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:IN
Practice Address - Zip Code:46774-2141
Practice Address - Country:US
Practice Address - Phone:260-493-3736
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-23
Last Update Date:2011-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26016653183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist