Provider Demographics
NPI:1992751143
Name:CORNER DRUG STORE, INC
Entity type:Organization
Organization Name:CORNER DRUG STORE, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CONTRACTING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:
Authorized Official - Last Name:DEANS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-992-6800
Mailing Address - Street 1:333 LOWVILLE RD
Mailing Address - Street 2:
Mailing Address - City:RIO
Mailing Address - State:WI
Mailing Address - Zip Code:53960-9437
Mailing Address - Country:US
Mailing Address - Phone:920-992-6800
Mailing Address - Fax:920-992-6801
Practice Address - Street 1:316 W SPRING ST STE 6
Practice Address - Street 2:
Practice Address - City:DODGEVILLE
Practice Address - State:WI
Practice Address - Zip Code:53533-1300
Practice Address - Country:US
Practice Address - Phone:608-935-3661
Practice Address - Fax:608-935-2661
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-26
Last Update Date:2025-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5538-042332B00000X, 3336C0003X
3336S0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33119600Medicaid
WI5105691OtherNCPDP
WI000080066Medicare PIN
WI5105691OtherNCPDP