Provider Demographics
NPI:1225323546
Name:CORNWELL, GARY DEAN (PHARMACIST)
Entity Type:Individual
Prefix:MR
First Name:GARY
Middle Name:DEAN
Last Name:CORNWELL
Suffix:
Gender:M
Credentials:PHARMACIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:609 N OAK ST
Mailing Address - Street 2:
Mailing Address - City:LINCOLNTON
Mailing Address - State:NC
Mailing Address - Zip Code:28092-2937
Mailing Address - Country:US
Mailing Address - Phone:704-732-1740
Mailing Address - Fax:704-732-1740
Practice Address - Street 1:609 NORTH OAK STREET
Practice Address - Street 2:
Practice Address - City:LINCOLNTON
Practice Address - State:NC
Practice Address - Zip Code:28092
Practice Address - Country:US
Practice Address - Phone:704-732-1740
Practice Address - Fax:704-732-1740
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-15
Last Update Date:2011-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5617183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist