Provider Demographics
NPI:1609152644
Name:CORNELL, DAVID BRUCE (RPH)
Entity Type:Individual
Prefix:MR
First Name:DAVID
Middle Name:BRUCE
Last Name:CORNELL
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 1:729 W HOUGHTON LAKE DR
Mailing Address - Street 2:
Mailing Address - City:PRUDENVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48651-8462
Mailing Address - Country:US
Mailing Address - Phone:989-366-5324
Mailing Address - Fax:989-366-9218
Practice Address - Street 1:729 W HOUGHTON LAKE DR
Practice Address - Street 2:
Practice Address - City:PRUDENVILLE
Practice Address - State:MI
Practice Address - Zip Code:48651-8462
Practice Address - Country:US
Practice Address - Phone:989-366-5324
Practice Address - Fax:989-366-9218
Is Sole Proprietor?:No
Enumeration Date:2011-10-21
Last Update Date:2011-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302021915183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist