1194866582 NPI number — KEYSTONE WHOLESALE CO

Table of content: (NPI 1194866582)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194866582 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:
KEY-MED PHARMACY CO.
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:
1194866582
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/07/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7328 MAPLE ST
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:
402-391-1524

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7328 MAPLE ST
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:
402-391-1524
Provider Enumeration Date:
02/09/2007

Additional Information

Authorized Official

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

Provider Taxonomy Codes

  • Taxonomy code: 3336C0003X , with the licence number:  1349 , registered in the state of NE ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 10025699700 , issued by the state of ( NE ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2800515 . This is a "NCPDP PROVIDER IDENTIFICATION NUMBER" identifier . This identifiers is of the category "OTHER".




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