Provider Demographics
NPI:1093206062
Name:KEYSTONERX CORPORATION, INC.
Entity Type:Organization
Organization Name:KEYSTONERX CORPORATION, INC.
Other - Org Name:DAVE'S PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:RANDOLPH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:308-760-1966
Mailing Address - Street 1:PO BOX 95
Mailing Address - Street 2:
Mailing Address - City:HEMINGFORD
Mailing Address - State:NE
Mailing Address - Zip Code:69348-0095
Mailing Address - Country:US
Mailing Address - Phone:308-762-4811
Mailing Address - Fax:
Practice Address - Street 1:223 BOX BUTTE AVE
Practice Address - Street 2:
Practice Address - City:ALLIANCE
Practice Address - State:NE
Practice Address - Zip Code:69301-3741
Practice Address - Country:US
Practice Address - Phone:308-762-4811
Practice Address - Fax:308-487-3409
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-24
Last Update Date:2018-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
NE7183336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE100264060-00Medicaid
2177805OtherPK