Provider Demographics
NPI:1932639937
Name:KEESEVILLE PHARMACY INC
Entity Type:Organization
Organization Name:KEESEVILLE PHARMACY INC
Other - Org Name:KEESEVILLE PHARMACY, INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:
Authorized Official - Last Name:BOSLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:518-834-6090
Mailing Address - Street 1:1730 FRONT ST
Mailing Address - Street 2:
Mailing Address - City:KEESEVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:12944-3618
Mailing Address - Country:US
Mailing Address - Phone:518-834-6090
Mailing Address - Fax:518-834-7021
Practice Address - Street 1:1730 FRONT ST
Practice Address - Street 2:
Practice Address - City:KEESEVILLE
Practice Address - State:NY
Practice Address - Zip Code:12944-3618
Practice Address - Country:US
Practice Address - Phone:518-834-6090
Practice Address - Fax:518-834-7021
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-06-13
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
NY0178343336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00775571Medicaid
2169937OtherPK