MEDICARE: S & R KEYSTONE PHARMACY LLC

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	333600000X	Pharmacy
2	3336C0003X	Community/Retail Pharmacy	P02060	MD

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	2113811	OTHER		NCPDP PROVIDER IDENTIFICATION NUMBER

General Provider Information

NPI Number	:	1063509255
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	S & R KEYSTONE PHARMACY LLC

Provider Business Mailing Address
First Line	:	1358 W NORTH AVE
Second Line	:
City	:	BALTIMORE
State	:	MD
Zip	:	21217-3536
Country	:	US
Telephone Number	:	410-669-1900
Fax Number	:	410-728-3375

Provider Business Practice Location Address
First Line	:	1358 W NORTH AVE
Second Line	:
City	:	BALTIMORE
State	:	MD
Zip	:	21217-3536
Country	:	US
Telephone Number	:	410-669-1900
Fax Number	:	410-728-3375

Authorized Official
Title or Position	:	MANAGING MEMBER
Name	:	MR. SYAM K POTLURI
Credential	:
Telephone Number	:	443-823-3350

Provider Enumeration Date	:	10/07/2006
Last Update Date	:	01/06/2022

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Directions to “S & R KEYSTONE PHARMACY LLC ” Practice Location

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