Provider Demographics
NPI:1326383498
Name:CORNER PHARMACY INC
Entity Type:Organization
Organization Name:CORNER PHARMACY INC
Other - Org Name:CORNER PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:YONGDONG
Authorized Official - Middle Name:
Authorized Official - Last Name:KIM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-622-6888
Mailing Address - Street 1:2550 PLEASANT HILL RD STE 120
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:GA
Mailing Address - Zip Code:30096-9278
Mailing Address - Country:US
Mailing Address - Phone:770-622-0688
Mailing Address - Fax:770-622-0689
Practice Address - Street 1:2550 PLEASANT HILL RD STE 120
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:GA
Practice Address - Zip Code:30096-9278
Practice Address - Country:US
Practice Address - Phone:770-622-0688
Practice Address - Fax:770-622-0689
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-30
Last Update Date:2016-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPHRE0098843336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2138096OtherPK
GA003141378AMedicaid