Provider Demographics
NPI:1366776486
Name:KIEDROW, KEITH JOHN (PHARMD)
Entity type:Individual
Prefix:DR
First Name:KEITH
Middle Name:JOHN
Last Name:KIEDROW
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2451 MIDTOWN AVE APT 211
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22303-1422
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10903 NEW HAMPSHIRE AVE
Practice Address - Street 2:WHITE OAK CDER BLDG 22, OFFICE 4242
Practice Address - City:SILVER SPRING
Practice Address - State:MD
Practice Address - Zip Code:20903-1058
Practice Address - Country:US
Practice Address - Phone:301-796-1924
Practice Address - Fax:301-796-9838
Is Sole Proprietor?:No
Enumeration Date:2009-09-22
Last Update Date:2009-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202205332183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist