Provider Demographics
NPI:1922132463
Name:KEAVENY KORNER DRUG INC
Entity Type:Organization
Organization Name:KEAVENY KORNER DRUG INC
Other - Org Name:KEAVENY KORNER DRUG
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DEBORAH
Authorized Official - Middle Name:
Authorized Official - Last Name:KEAVENY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:612-227-7811
Mailing Address - Street 1:PO BOX 249
Mailing Address - Street 2:
Mailing Address - City:CLARA CITY
Mailing Address - State:MN
Mailing Address - Zip Code:56222-0249
Mailing Address - Country:US
Mailing Address - Phone:320-847-3784
Mailing Address - Fax:320-847-3837
Practice Address - Street 1:110 MAIN ST
Practice Address - Street 2:
Practice Address - City:CLARA CITY
Practice Address - State:MN
Practice Address - Zip Code:56222
Practice Address - Country:US
Practice Address - Phone:320-847-3784
Practice Address - Fax:320-847-3787
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-15
Last Update Date:2013-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2639783336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2138315OtherPK