Provider Demographics
NPI:1497174825
Name:CORNERSTONE PHARMACY KENNETT
Entity Type:Organization
Organization Name:CORNERSTONE PHARMACY KENNETT
Other - Org Name:CORNERSTONE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:
Authorized Official - Last Name:SCOTT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-888-9094
Mailing Address - Street 1:123 1ST ST
Mailing Address - Street 2:
Mailing Address - City:KENNETT
Mailing Address - State:MO
Mailing Address - Zip Code:63857-2051
Mailing Address - Country:US
Mailing Address - Phone:573-888-9094
Mailing Address - Fax:573-888-5946
Practice Address - Street 1:123 1ST ST
Practice Address - Street 2:
Practice Address - City:KENNETT
Practice Address - State:MO
Practice Address - Zip Code:63857-2051
Practice Address - Country:US
Practice Address - Phone:573-888-9094
Practice Address - Fax:573-888-5946
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-14
Last Update Date:2014-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20140122933336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2145605OtherPK
MO1497174825Medicaid