Provider Demographics
NPI:1033283502
Name:THE CORNER DRUGSTORE INC
Entity Type:Organization
Organization Name:THE CORNER DRUGSTORE INC
Other - Org Name:STANDARD DRUG #10
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:GERALD
Authorized Official - Middle Name:W
Authorized Official - Last Name:ROBERTS
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:636-946-6557
Mailing Address - Street 1:1251 WENTZVILLE PKWY
Mailing Address - Street 2:
Mailing Address - City:WENTZVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:63385-3749
Mailing Address - Country:US
Mailing Address - Phone:636-887-4399
Mailing Address - Fax:636-887-4371
Practice Address - Street 1:1251 WENTZVILLE PKWY
Practice Address - Street 2:
Practice Address - City:WENTZVILLE
Practice Address - State:MO
Practice Address - Zip Code:63385-3749
Practice Address - Country:US
Practice Address - Phone:636-887-4399
Practice Address - Fax:636-887-4371
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-17
Last Update Date:2008-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO042894333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO11478594OtherSTATE TAX ID
MO2006035983OtherSTATE LICENSE
MO2006035983OtherSTATE LICENSE