Provider Demographics
NPI:1336132588
Name:CORYDON PHARMACY INC
Entity Type:Organization
Organization Name:CORYDON PHARMACY INC
Other - Org Name:NESSEN PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT AND OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:NESSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:641-872-2512
Mailing Address - Street 1:PO BOX 385
Mailing Address - Street 2:
Mailing Address - City:CORYDON
Mailing Address - State:IA
Mailing Address - Zip Code:50060-0385
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:104 S FRANKLIN ST
Practice Address - Street 2:
Practice Address - City:CORYDON
Practice Address - State:IA
Practice Address - Zip Code:50060-1518
Practice Address - Country:US
Practice Address - Phone:641-872-2512
Practice Address - Fax:641-872-1078
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-23
Last Update Date:2010-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA5953336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO602208407Medicaid
IA085902Medicaid
1605469OtherNCPDP PROVIDER IDENTIFICATION NUMBER
MO602208407Medicaid