Provider Demographics
NPI:1194790469
Name:THE CORNER PHARMACY, INC.
Entity type:Organization
Organization Name:THE CORNER PHARMACY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:R
Authorized Official - Last Name:BOOTH
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:913-682-1602
Mailing Address - Street 1:429 DELAWARE ST
Mailing Address - Street 2:
Mailing Address - City:LEAVENWORTH
Mailing Address - State:KS
Mailing Address - Zip Code:66048-2732
Mailing Address - Country:US
Mailing Address - Phone:913-682-1602
Mailing Address - Fax:913-682-4220
Practice Address - Street 1:429 DELAWARE ST
Practice Address - Street 2:
Practice Address - City:LEAVENWORTH
Practice Address - State:KS
Practice Address - Zip Code:66048-2732
Practice Address - Country:US
Practice Address - Phone:913-682-1602
Practice Address - Fax:913-682-4220
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-21
Last Update Date:2007-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS206059333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS1710652OtherNABP
KS0574940001Medicare ID - Type Unspecified