Provider Demographics
NPI:1194942292
Name:CORNER PRESCRIPTION SHOPPE INC
Entity type:Organization
Organization Name:CORNER PRESCRIPTION SHOPPE INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRES
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:BORDES
Authorized Official - Suffix:
Authorized Official - Credentials:BACHELOR OF SCI
Authorized Official - Phone:606-549-0884
Mailing Address - Street 1:401 SYCAMORE ST
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSBURG
Mailing Address - State:KY
Mailing Address - Zip Code:40769-1136
Mailing Address - Country:US
Mailing Address - Phone:606-549-0884
Mailing Address - Fax:606-539-0860
Practice Address - Street 1:401 SYCAMORE ST
Practice Address - Street 2:
Practice Address - City:WILLIAMSBURG
Practice Address - State:KY
Practice Address - Zip Code:40769-1136
Practice Address - Country:US
Practice Address - Phone:606-549-0884
Practice Address - Fax:606-539-0860
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-19
Last Update Date:2016-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
KYP015653336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2030349OtherPK
KY54018171Medicaid
KY90151184Medicaid
2030349OtherPK