Basic Information
| Provider Information | |||||||||
| NPI: | 1538619614 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | KEYSTONE PHARMACY SERVICES LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | THE PHARMACY AT LSU | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 10360 DEERBORN LANE | ||||||||
| Address2: | |||||||||
| City: | KNOXILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 37932 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8656717800 | ||||||||
| FaxNumber: | 8656710064 | ||||||||
| Practice Location | |||||||||
| Address1: | BROUSSARD ATHLETIC TRAINING CTR | ||||||||
| Address2: | NORTH STADIUM DRIVE | ||||||||
| City: | BATON ROUGE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 708030001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2255780681 | ||||||||
| FaxNumber: | 2255783924 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/12/2016 | ||||||||
| LastUpdateDate: | 07/19/2018 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | JAFFURS | ||||||||
| AuthorizedOfficialFirstName: | CHRIS | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 8656717787 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 333600000X | N | Suppliers | Pharmacy | 3336I0012X | PHY.007379-IR | LA | Y | Suppliers | Pharmacy | Institutional Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 2164516 | 01 | PK | OTHER |