Provider Demographics
NPI:1063705408
Name:CORNER DRUG STORE
Entity type:Organization
Organization Name:CORNER DRUG STORE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:DANIEL
Authorized Official - Last Name:DUCK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-539-3199
Mailing Address - Street 1:27 REYNOLDS ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGHILL
Mailing Address - State:LA
Mailing Address - Zip Code:71075-3241
Mailing Address - Country:US
Mailing Address - Phone:318-539-3199
Mailing Address - Fax:318-539-3197
Practice Address - Street 1:27 REYNOLDS ST
Practice Address - Street 2:
Practice Address - City:SPRINGHILL
Practice Address - State:LA
Practice Address - Zip Code:71075-3241
Practice Address - Country:US
Practice Address - Phone:318-539-3199
Practice Address - Fax:318-539-3197
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-18
Last Update Date:2025-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
2129743OtherPK
AR187472407Medicaid
LA2200836Medicaid
1935660OtherNCPDP PROVIDER IDENTIFICATION NUMBER
AROS02294OtherARKANSAS PHARMACY