Provider Demographics
NPI:1568892164
Name:CORNERSTONE PHARMACY OTTER CREEK LLC
Entity Type:Organization
Organization Name:CORNERSTONE PHARMACY OTTER CREEK LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PIC
Authorized Official - Prefix:
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:SHELLEY
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:501-455-1900
Mailing Address - Street 1:10320 STAGECOACH RD
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72210-5746
Mailing Address - Country:US
Mailing Address - Phone:501-455-1900
Mailing Address - Fax:501-455-0500
Practice Address - Street 1:10320 STAGECOACH RD
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72210-5746
Practice Address - Country:US
Practice Address - Phone:501-455-1900
Practice Address - Fax:501-455-0500
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-18
Last Update Date:2022-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR1468892164OtherNPI
AR7523000001OtherPTAN
AR1468892164OtherNPI