Provider Demographics
NPI:1609271220
Name:CORNER CROSSING LLC
Entity Type:Organization
Organization Name:CORNER CROSSING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, PIC, AO
Authorized Official - Prefix:
Authorized Official - First Name:JT
Authorized Official - Middle Name:
Authorized Official - Last Name:LEATHERWOOD
Authorized Official - Suffix:
Authorized Official - Credentials:BS PHARMACY
Authorized Official - Phone:256-230-6200
Mailing Address - Street 1:30694 HIGHWAY 72 WEST
Mailing Address - Street 2:SUITE A
Mailing Address - City:HUNTSVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35756
Mailing Address - Country:US
Mailing Address - Phone:256-230-6200
Mailing Address - Fax:256-230-6232
Practice Address - Street 1:30694 HIGHWAY 72 WEST
Practice Address - Street 2:SUITE A
Practice Address - City:HUNTSVILLE
Practice Address - State:AL
Practice Address - Zip Code:35756
Practice Address - Country:US
Practice Address - Phone:256-230-6200
Practice Address - Fax:256-230-6232
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-24
Last Update Date:2018-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
AL1145003336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL176134Medicaid
2150075OtherPK