MEDICARE: KEYSTONE PHARMACY INC

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
3	3336C0004X	Compounding Pharmacy	5301007431	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2045985	OTHER		PK
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1316049745
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KEYSTONE PHARMACY INC

Provider Business Mailing Address
First Line	:	4021 CASCADE RD SE
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49546-2177
Country	:	US
Telephone Number	:	616-974-9792
Fax Number	:	616-464-3469

Provider Business Practice Location Address
First Line	:	4021 CASCADE RD SE
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49546-2177
Country	:	US
Telephone Number	:	616-974-9792
Fax Number	:	616-464-3469

Authorized Official
Title or Position	:	OWNER
Name	:	DAVID MILLER
Credential	:	R.PH., PH.D.
Telephone Number	:	616-974-9792

Provider Enumeration Date	:	09/05/2006
Last Update Date	:	03/17/2017

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Directions to “KEYSTONE PHARMACY INC ” Practice Location

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