Provider Demographics
NPI:1952413957
Name:KEITHS DRIVE IN DRUGS INC
Entity Type:Organization
Organization Name:KEITHS DRIVE IN DRUGS INC
Other - Org Name:KEITHS MEDICAL PARK PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:PATRICIA
Authorized Official - Middle Name:JEAN
Authorized Official - Last Name:GOLLNER
Authorized Official - Suffix:
Authorized Official - Credentials:PHARM D RP
Authorized Official - Phone:402-462-6101
Mailing Address - Street 1:2115 N KANSAS AVE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:HASTINGS
Mailing Address - State:NE
Mailing Address - Zip Code:68901-2640
Mailing Address - Country:US
Mailing Address - Phone:402-463-0515
Mailing Address - Fax:402-463-5254
Practice Address - Street 1:2115 N KANSAS AVE
Practice Address - Street 2:
Practice Address - City:HASTINGS
Practice Address - State:NE
Practice Address - Zip Code:68901-2640
Practice Address - Country:US
Practice Address - Phone:402-463-0515
Practice Address - Fax:402-463-5254
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2022-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
NE21533336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2054225OtherPK
NE=========01Medicaid