Provider Demographics
NPI:1043546799
Name:CORNERSTONE PHARMACY OF BELLA VISTA LLC
Entity Type:Organization
Organization Name:CORNERSTONE PHARMACY OF BELLA VISTA LLC
Other - Org Name:CORNERSTONE PHARMACY OF BELLA VISTA, LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO, OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:GRAHAM
Authorized Official - Suffix:
Authorized Official - Credentials:PHD, PHARM D
Authorized Official - Phone:479-876-6200
Mailing Address - Street 1:1 MERCY WAY
Mailing Address - Street 2:STE 50
Mailing Address - City:BELLA VISTA
Mailing Address - State:AR
Mailing Address - Zip Code:72714-3000
Mailing Address - Country:US
Mailing Address - Phone:479-876-6200
Mailing Address - Fax:479-876-2232
Practice Address - Street 1:1 MERCY WAY STE 50
Practice Address - Street 2:
Practice Address - City:BELLA VISTA
Practice Address - State:AR
Practice Address - Zip Code:72714-3000
Practice Address - Country:US
Practice Address - Phone:479-876-6200
Practice Address - Fax:479-876-2232
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-29
Last Update Date:2015-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARAR20616333600000X
3336C0003X, 3336C0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2122774OtherPK
AR183982407Medicaid