Provider Demographics
NPI:1487698171
Name:KEYMED INC
Entity type:Organization
Organization Name:KEYMED INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:MILLS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-233-2444
Mailing Address - Street 1:3607 POLE LINE RD
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-5531
Mailing Address - Country:US
Mailing Address - Phone:208-233-2444
Mailing Address - Fax:208-233-3439
Practice Address - Street 1:3607 POLE LINE RD
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-5531
Practice Address - Country:US
Practice Address - Phone:208-233-2444
Practice Address - Fax:208-233-3439
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-15
Last Update Date:2022-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID1901LS3336L0003X
ID44701LS3336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID807012000Medicaid
ID5302860001Medicare NSC