Provider Demographics
NPI:1316014889
Name:CORNERSTONE PHARMACY
Entity Type:Organization
Organization Name:CORNERSTONE PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DAILEY
Authorized Official - Middle Name:L
Authorized Official - Last Name:SHROUT
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:304-329-0193
Mailing Address - Street 1:425 E MAIN ST
Mailing Address - Street 2:STE 409
Mailing Address - City:KINGWOOD
Mailing Address - State:WV
Mailing Address - Zip Code:26537
Mailing Address - Country:US
Mailing Address - Phone:304-329-0193
Mailing Address - Fax:304-329-3151
Practice Address - Street 1:425 E MAIN ST
Practice Address - Street 2:STE 409
Practice Address - City:KINGWOOD
Practice Address - State:WV
Practice Address - Zip Code:26537
Practice Address - Country:US
Practice Address - Phone:304-329-0193
Practice Address - Fax:304-329-3151
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-29
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVMP0552287333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV6001242000Medicaid
WV6001242000Medicaid