Provider Demographics
NPI:1184231920
Name:KEYSTONERX CORPORATION, INC.
Entity Type:Organization
Organization Name:KEYSTONERX CORPORATION, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:BLANCHE
Authorized Official - Middle Name:ANNE
Authorized Official - Last Name:RANDOLPH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:308-487-5212
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:308-487-5212
Mailing Address - Fax:308-487-5235
Practice Address - Street 1:508 NIOBRARA AVE
Practice Address - Street 2:
Practice Address - City:HEMINGFORD
Practice Address - State:NE
Practice Address - Zip Code:69348-9703
Practice Address - Country:US
Practice Address - Phone:308-487-5212
Practice Address - Fax:308-487-5235
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-09-25
Last Update Date:2020-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE100264060Medicaid