Provider Demographics
NPI:1033243845
Name:KEALEY PHARMACY & HOME CARE CENTER
Entity Type:Organization
Organization Name:KEALEY PHARMACY & HOME CARE CENTER
Other - Org Name:KEALEY PHARMACY AND HOMECARE INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER / PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:608-752-7869
Mailing Address - Street 1:PO BOX 8005
Mailing Address - Street 2:
Mailing Address - City:JANESVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53547-8005
Mailing Address - Country:US
Mailing Address - Phone:608-752-7869
Mailing Address - Fax:608-752-6806
Practice Address - Street 1:21 S JACKSON ST
Practice Address - Street 2:
Practice Address - City:JANESVILLE
Practice Address - State:WI
Practice Address - Zip Code:53548-3859
Practice Address - Country:US
Practice Address - Phone:608-752-7869
Practice Address - Fax:608-752-6806
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-15
Last Update Date:2013-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X, 3336C0004X
WI7301-0423336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2111847OtherPK
WI33117200Medicaid
1033243845Medicare NSC