Provider Demographics
NPI:1710929054
Name:CORNER DRUG STORE OF STURGIS, LLC
Entity Type:Organization
Organization Name:CORNER DRUG STORE OF STURGIS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:DAREN
Authorized Official - Last Name:WARFORD
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:270-333-5344
Mailing Address - Street 1:424 N ADAMS ST
Mailing Address - Street 2:
Mailing Address - City:STURGIS
Mailing Address - State:KY
Mailing Address - Zip Code:42459-1611
Mailing Address - Country:US
Mailing Address - Phone:270-333-5344
Mailing Address - Fax:270-333-4513
Practice Address - Street 1:424 N ADAMS ST
Practice Address - Street 2:
Practice Address - City:STURGIS
Practice Address - State:KY
Practice Address - Zip Code:42459-1611
Practice Address - Country:US
Practice Address - Phone:270-333-5344
Practice Address - Fax:270-333-4513
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYP069403336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY1808560OtherNCPDP NUMBER
KY54007877Medicaid
KY90008897Medicaid
KY1808560OtherNCPDP NUMBER