Provider Demographics
NPI:1225787278
Name:THE CORNER DRUG STORE
Entity Type:Organization
Organization Name:THE CORNER DRUG STORE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PIC/PHARMACIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:STEVE
Authorized Official - Middle Name:LARRY
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:JR
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:228-687-3040
Mailing Address - Street 1:5101 BEATLINE ROAD
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:MS
Mailing Address - Zip Code:39560
Mailing Address - Country:US
Mailing Address - Phone:228-687-3040
Mailing Address - Fax:228-687-3041
Practice Address - Street 1:5101 BEATLINE ROAD
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:MS
Practice Address - Zip Code:39560
Practice Address - Country:US
Practice Address - Phone:228-687-3040
Practice Address - Fax:228-687-3041
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-03-18
Last Update Date:2022-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy