Provider Demographics
NPI:1194866582
Name:KEYSTONE WHOLESALE CO
Entity type:Organization
Organization Name:KEYSTONE WHOLESALE CO
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRES
Authorized Official - Prefix:
Authorized Official - First Name:MANNY
Authorized Official - Middle Name:
Authorized Official - Last Name:GOLDBERG
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:402-391-2659
Mailing Address - Street 1:7328 MAPLE ST
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68134-6829
Mailing Address - Country:US
Mailing Address - Phone:402-391-2659
Mailing Address - Fax:402-391-1524
Practice Address - Street 1:7328 MAPLE ST
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68134-6829
Practice Address - Country:US
Practice Address - Phone:402-391-2659
Practice Address - Fax:402-391-1524
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-09
Last Update Date:2010-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE13493336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10025699700Medicaid
2800515OtherNCPDP PROVIDER IDENTIFICATION NUMBER
NE10025699700Medicaid