=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114071800
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KEAVENY DRUG INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/22/2007
-----------------------------------------------------
Last Update Date | 02/25/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 150 MAIN AVE W
-----------------------------------------------------
City | WINSTED
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55395-7872
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 320-485-2555
-----------------------------------------------------
Fax | 320-485-4266
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 910
-----------------------------------------------------
City | WINSTED
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55395-0910
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 320-485-2555
-----------------------------------------------------
Fax | 320-485-4266
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DEBORAH KEAVENY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 612-791-6687
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 333600000X
-----------------------------------------------------
Taxonomy Name | Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 3336L0003X
-----------------------------------------------------
Taxonomy Name | Long Term Care Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | 263701
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------