Provider Demographics
NPI:1508919119
Name:CORNELL CENTRUM PHARMACY
Entity Type:Organization
Organization Name:CORNELL CENTRUM PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACY OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:TONY
Authorized Official - Middle Name:E
Authorized Official - Last Name:JONES
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:303-694-3784
Mailing Address - Street 1:8200 E BELLEVIEW AVE
Mailing Address - Street 2:100C
Mailing Address - City:GREENWOOD VILLAGE
Mailing Address - State:CO
Mailing Address - Zip Code:80111-2803
Mailing Address - Country:US
Mailing Address - Phone:303-694-3784
Mailing Address - Fax:
Practice Address - Street 1:8200 E BELLEVIEW AVE
Practice Address - Street 2:100C
Practice Address - City:GREENWOOD VILLAGE
Practice Address - State:CO
Practice Address - Zip Code:80111-2803
Practice Address - Country:US
Practice Address - Phone:303-694-3784
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-18
Last Update Date:2008-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO3700000173336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy