1184736001 NPI number — BRIAN FONTAINE KEYS

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1184736001 NPI number — BRIAN FONTAINE KEYS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BRIAN FONTAINE KEYS
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
COMMUNITY PROFESSIONAL PHARMACY
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1184736001
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/19/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4510 BROCKTON AVE STE 107
Provider Second Line Business Mailing Address:
STE 107
Provider Business Mailing Address City Name:
RIVERSIDE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92501-4020
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
951-683-1200
Provider Business Mailing Address Fax Number:
951-683-8078

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4510 BROCKTON AVE STE 107
Provider Second Line Business Practice Location Address:
STE 107
Provider Business Practice Location Address City Name:
RIVERSIDE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92501-4020
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
951-683-1200
Provider Business Practice Location Address Fax Number:
951-683-8078
Provider Enumeration Date:
08/31/2006

Additional Information

Authorized Official

Authorized Official Last Name:
KEYES
Authorized Official First Name:
BRIAN
Authorized Official Middle Name:
Authorized Official Title or Position:
RPH
Authorized Official Telephone Number:
951-683-1200

Provider Taxonomy Codes

  • Taxonomy code: 333600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X , with the licence number: PHY22224 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 3336C0004X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 2116108 . This is a "PK" identifier . This identifiers is of the category "OTHER".
  • Identifier: PHY22224 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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