Provider Demographics
NPI:1992072078
Name:DAHLER, KEITH JAMES (RPH)
Entity type:Individual
Prefix:MR
First Name:KEITH
Middle Name:JAMES
Last Name:DAHLER
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:735 W STADIUM BLVD
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON CITY
Mailing Address - State:MO
Mailing Address - Zip Code:65109-4753
Mailing Address - Country:US
Mailing Address - Phone:573-893-1079
Mailing Address - Fax:573-893-1079
Practice Address - Street 1:735 W STADIUM BLVD
Practice Address - Street 2:
Practice Address - City:JEFFERSON CITY
Practice Address - State:MO
Practice Address - Zip Code:65109-4753
Practice Address - Country:US
Practice Address - Phone:573-893-1079
Practice Address - Fax:573-893-1079
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-17
Last Update Date:2011-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO029067183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist