Provider Demographics
NPI:1083941462
Name:CORN, MARILYN (R,PH)
Entity Type:Individual
Prefix:
First Name:MARILYN
Middle Name:
Last Name:CORN
Suffix:
Gender:F
Credentials:R,PH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6707 W NORTHWEST HWY
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75225-4201
Mailing Address - Country:US
Mailing Address - Phone:214-361-4637
Mailing Address - Fax:214-360-9018
Practice Address - Street 1:6707 W NORTHWEST HWY
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75225-4201
Practice Address - Country:US
Practice Address - Phone:214-361-4637
Practice Address - Fax:214-360-9018
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-05
Last Update Date:2009-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX25412183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist