Provider Demographics
NPI:1720536881
Name:CORNETT, ERIK
Entity Type:Individual
Prefix:
First Name:ERIK
Middle Name:
Last Name:CORNETT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:212 N PARK AVE
Mailing Address - Street 2:
Mailing Address - City:HERRIN
Mailing Address - State:IL
Mailing Address - Zip Code:62948-3150
Mailing Address - Country:US
Mailing Address - Phone:618-942-6900
Mailing Address - Fax:
Practice Address - Street 1:212 N PARK AVE
Practice Address - Street 2:
Practice Address - City:HERRIN
Practice Address - State:IL
Practice Address - Zip Code:62948-3150
Practice Address - Country:US
Practice Address - Phone:618-942-6900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-19
Last Update Date:2016-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051286992183500000X
TN38073183500000X
KY017094183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist