Provider Demographics
NPI:1417370438
Name:CORNER PHARMACY
Entity Type:Organization
Organization Name:CORNER PHARMACY
Other - Org Name:THE CORNER PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TAREK
Authorized Official - Middle Name:
Authorized Official - Last Name:JAWARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:313-674-9800
Mailing Address - Street 1:15525 W WARREN AVE
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48228-3731
Mailing Address - Country:US
Mailing Address - Phone:313-584-3377
Mailing Address - Fax:313-584-8336
Practice Address - Street 1:15525 W WARREN AVE
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48228-3731
Practice Address - Country:US
Practice Address - Phone:313-584-3377
Practice Address - Fax:313-584-8336
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-27
Last Update Date:2014-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI53010072563336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2144296OtherPK