Healthcare Provider Details

I. General information

NPI: 1407109457
Provider Name (Legal Business Name): KEYSTONE PHARMACY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/15/2012
Last Update Date: 04/14/2026
Certification Date: 04/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

106 HIGHLAND WAY STE 206
MADISON MS
39110-6930
US

IV. Provider business mailing address

106 HIGHLAND WAY SUITE 206
MADISON MS
39110-6929
US

V. Phone/Fax

Practice location:
  • Phone: 601-707-9727
  • Fax: 601-510-3846
Mailing address:
  • Phone: 601-707-9727
  • Fax: 601-510-3846

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3336M0002X
TaxonomyMail Order Pharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number11702
License Number StateMS
# 3
Primary TaxonomyN
Taxonomy Code3336S0011X
TaxonomySpecialty Pharmacy
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State

VIII. Authorized Official

Name: JEFFERY KING
Title or Position: CHIEF CLINICAL OFFICER
Credential:
Phone: 601-707-9727