Provider Demographics
NPI:1528378205
Name:CORNWELL, DAVID (RPH)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:CORNWELL
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1007 ALAMOSA STREET
Mailing Address - Street 2:
Mailing Address - City:NEW LENOX
Mailing Address - State:IL
Mailing Address - Zip Code:60451
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1007 ALAMOSA STREET
Practice Address - Street 2:
Practice Address - City:NEW LENOX
Practice Address - State:IL
Practice Address - Zip Code:60451
Practice Address - Country:US
Practice Address - Phone:815-725-1102
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-15
Last Update Date:2010-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051032392183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist