Provider Demographics
NPI:1104179274
Name:CORNERSTONE PHARMACY JFK LLC
Entity Type:Organization
Organization Name:CORNERSTONE PHARMACY JFK LLC
Other - Org Name:CORNERSTONE PHARMACY JFK, LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PARTNER/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KENNY
Authorized Official - Middle Name:
Authorized Official - Last Name:HARRISON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:501-580-1895
Mailing Address - Street 1:5328 JFK BLVD
Mailing Address - Street 2:
Mailing Address - City:NORTH LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72116-6704
Mailing Address - Country:US
Mailing Address - Phone:501-246-5035
Mailing Address - Fax:501-246-5448
Practice Address - Street 1:5328 JOHN F KENNEDY BLVD
Practice Address - Street 2:
Practice Address - City:NORTH LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72116-6704
Practice Address - Country:US
Practice Address - Phone:501-246-5035
Practice Address - Fax:501-246-5448
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-25
Last Update Date:2017-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
ARAR206893336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2136806OtherPK
AR196600407Medicaid