Provider Demographics
NPI:1023014255
Name:CORNELLS PHARMACY LLC
Entity Type:Organization
Organization Name:CORNELLS PHARMACY LLC
Other - Org Name:CORNELLS PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MARCIA
Authorized Official - Middle Name:
Authorized Official - Last Name:TRISKA
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:419-374-2033
Mailing Address - Street 1:PO BOX 645
Mailing Address - Street 2:
Mailing Address - City:SHELBY
Mailing Address - State:OH
Mailing Address - Zip Code:44875-0645
Mailing Address - Country:US
Mailing Address - Phone:419-347-2033
Mailing Address - Fax:419-347-2053
Practice Address - Street 1:140 MANSFIELD AVE
Practice Address - Street 2:
Practice Address - City:SHELBY
Practice Address - State:OH
Practice Address - Zip Code:44875-1833
Practice Address - Country:US
Practice Address - Phone:419-347-2033
Practice Address - Fax:419-347-2053
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-22
Last Update Date:2011-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
OH0212746503336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
3669554OtherNCPDP PROVIDER IDENTIFICATION NUMBER
OH2256320Medicaid
3669554OtherNCPDP PROVIDER IDENTIFICATION NUMBER