Healthcare Provider Details

I. General information

NPI: 1497722128
Provider Name (Legal Business Name): KELLER & MUNRO INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/01/2006
Last Update Date: 10/04/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

127 E CHURCH ST
LOCK HAVEN PA
17745-2007
US

IV. Provider business mailing address

127 E CHURCH ST
LOCK HAVEN PA
17745-2007
US

V. Phone/Fax

Practice location:
  • Phone: 570-748-5209
  • Fax: 570-748-7390
Mailing address:
  • Phone: 570-748-5209
  • Fax: 570-748-7390

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier0012414660002
Identifier TypeMEDICAID
Identifier StatePA
Identifier Issuer
# 2
Identifier3919226
Identifier TypeOTHER
Identifier StatePA
Identifier IssuerNABP #

VIII. Authorized Official

Name: MR. JEFFREY LEE PACKECH
Title or Position: PRESIDENT
Credential: R.PH.
Phone: 570-748-5209