Provider Demographics
NPI:1679807481
Name:KEITH, JIMMY DALE JR (RPH)
Entity type:Individual
Prefix:
First Name:JIMMY
Middle Name:DALE
Last Name:KEITH
Suffix:JR
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 1:1427A NC HIGHWAY 68 N
Mailing Address - Street 2:
Mailing Address - City:OAK RIDGE
Mailing Address - State:NC
Mailing Address - Zip Code:27310-9768
Mailing Address - Country:US
Mailing Address - Phone:336-703-7580
Mailing Address - Fax:
Practice Address - Street 1:207 OAKWAY RIDGE CT
Practice Address - Street 2:
Practice Address - City:KERNERSVILLE
Practice Address - State:NC
Practice Address - Zip Code:27284-7455
Practice Address - Country:US
Practice Address - Phone:336-992-6814
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-25
Last Update Date:2023-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC10715183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist