1003982307 NPI number — KEYSTONE WHOLESALE CO

Table of content: (NPI 1003982307)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003982307 NPI number — KEYSTONE WHOLESALE CO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KEYSTONE WHOLESALE CO
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:
MEDICINE CHEST HOME CARE
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:
1003982307
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/11/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7328 MAPLE STREET
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OMAHA
Provider Business Mailing Address State Name:
NE
Provider Business Mailing Address Postal Code:
68134-6829
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
402-391-2659
Provider Business Mailing Address Fax Number:
402-391-0038

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7328 MAPLE STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OMAHA
Provider Business Practice Location Address State Name:
NE
Provider Business Practice Location Address Postal Code:
68134-6829
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
402-391-2659
Provider Business Practice Location Address Fax Number:
402-391-0038
Provider Enumeration Date:
11/28/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
GOLDBERG
Authorized Official First Name:
MANNY
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
402-391-2659

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 332BC3200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 332BP3500X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 332BX2000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 1125096 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 93081454401 , issued by the state of ( NE ) . This identifiers is of the category "MEDICAID".
  • Identifier: 9942 . This is a "BCBS" identifier , issued by the state of ( NE ) . This identifiers is of the category "OTHER".
  • Identifier: 9942 . This is a "BCBS" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".