Provider Demographics
NPI:1407109457
Name:KEYSTONE PHARMACY LLC
Entity Type:Organization
Organization Name:KEYSTONE PHARMACY LLC
Other - Org Name:KEYSTONE PHARMACY LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KIM
Authorized Official - Middle Name:
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-707-9727
Mailing Address - Street 1:106 HIGHLAND WAY
Mailing Address - Street 2:SUITE 206
Mailing Address - City:MADISON
Mailing Address - State:MS
Mailing Address - Zip Code:39110-6929
Mailing Address - Country:US
Mailing Address - Phone:601-707-9727
Mailing Address - Fax:601-510-3846
Practice Address - Street 1:106 HIGHLAND WAY STE 206
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:MS
Practice Address - Zip Code:39110-6930
Practice Address - Country:US
Practice Address - Phone:601-707-9727
Practice Address - Fax:601-510-3846
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-15
Last Update Date:2024-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X, 3336C0004X, 3336M0002X, 3336S0011X
MS117023336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336M0002XSuppliersPharmacyMail Order Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2145389OtherPK