=====================================================
General NPI Number Information
=====================================================
NPI Number | 1730758046
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KEYSTONE PHARMACY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/21/2021
-----------------------------------------------------
Last Update Date | 06/21/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9133 W THUNDERBIRD RD STE 101
-----------------------------------------------------
City | PEORIA
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85381-4269
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 602-767-0606
-----------------------------------------------------
Fax | 602-767-0568
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9133 W THUNDERBIRD RD STE 101
-----------------------------------------------------
City | PEORIA
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85381-4269
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 602-767-0606
-----------------------------------------------------
Fax | 602-767-0568
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | VINEETH NADIMPALLY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 602-767-0606
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------