1184231920 NPI number — KEYSTONE RX CORPORATION INC

Table of content: (NPI 1184231920)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1184231920 NPI number — KEYSTONE RX CORPORATION INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KEYSTONE RX CORPORATION INC
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:
Provider Other Organization Name Type Code:
6
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:
1184231920
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/17/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 95
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HEMINGFORD
Provider Business Mailing Address State Name:
NE
Provider Business Mailing Address Postal Code:
69348-0095
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
308-487-5212
Provider Business Mailing Address Fax Number:
308-487-5235

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
508 NIOBRARA AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HEMINGFORD
Provider Business Practice Location Address State Name:
NE
Provider Business Practice Location Address Postal Code:
69348-9703
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
308-487-5212
Provider Business Practice Location Address Fax Number:
308-487-5235
Provider Enumeration Date:
09/25/2020

Additional Information

Authorized Official

Authorized Official Last Name:
RANDOLPH
Authorized Official First Name:
BLANCHE
Authorized Official Middle Name:
ANNE
Authorized Official Title or Position:
OWNER/MANAGER
Authorized Official Telephone Number:
308-487-5212

Provider Taxonomy Codes

  • Taxonomy code: 3336L0003X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 100264060 , issued by the state of ( NE ) . This identifiers is of the category "MEDICAID".




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