MEDICARE: KEAVENY KORNER DRUG INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	3336C0003X	Community/Retail Pharmacy	263978	MN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2138315	OTHER		PK

General Provider Information

NPI Number	:	1922132463
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KEAVENY KORNER DRUG INC

Provider Business Mailing Address
First Line	:	PO BOX 249
Second Line	:
City	:	CLARA CITY
State	:	MN
Zip	:	56222-0249
Country	:	US
Telephone Number	:	320-847-3784
Fax Number	:	320-847-3837

Provider Business Practice Location Address
First Line	:	110 MAIN ST
Second Line	:
City	:	CLARA CITY
State	:	MN
Zip	:	56222
Country	:	US
Telephone Number	:	320-847-3784
Fax Number	:	320-847-3787

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DEBORAH KEAVENY
Credential	:
Telephone Number	:	612-227-7811

Provider Enumeration Date	:	03/15/2007
Last Update Date	:	04/25/2013

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