Provider Demographics
NPI:1023016342
Name:KETNER INVESTMENT CORP
Entity Type:Organization
Organization Name:KETNER INVESTMENT CORP
Other - Org Name:KETNER PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:LAURENCE
Authorized Official - Middle Name:D
Authorized Official - Last Name:KETNER
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:207-743-8121
Mailing Address - Street 1:54 FAIR ST
Mailing Address - Street 2:
Mailing Address - City:NORWAY
Mailing Address - State:ME
Mailing Address - Zip Code:04268-5628
Mailing Address - Country:US
Mailing Address - Phone:207-743-8121
Mailing Address - Fax:207-744-0246
Practice Address - Street 1:54 FAIR ST
Practice Address - Street 2:
Practice Address - City:NORWAY
Practice Address - State:ME
Practice Address - Zip Code:04268-5628
Practice Address - Country:US
Practice Address - Phone:207-743-8121
Practice Address - Fax:207-744-0246
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPH50001093333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
0291080001Medicare ID - Type Unspecified