Provider Demographics
NPI:1760477079
Name:CORNER DRUG CO. INC.
Entity Type:Organization
Organization Name:CORNER DRUG CO. INC.
Other - Org Name:CORNER DRUG COMPANY INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRES
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:SHELLEY
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:530-662-2813
Mailing Address - Street 1:PO BOX 1812
Mailing Address - Street 2:
Mailing Address - City:WOODLAND
Mailing Address - State:CA
Mailing Address - Zip Code:95776-1812
Mailing Address - Country:US
Mailing Address - Phone:530-662-2813
Mailing Address - Fax:
Practice Address - Street 1:602 MAIN ST
Practice Address - Street 2:
Practice Address - City:WOODLAND
Practice Address - State:CA
Practice Address - Zip Code:95695-3405
Practice Address - Country:US
Practice Address - Phone:530-662-2813
Practice Address - Fax:530-662-1031
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-13
Last Update Date:2019-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
CAPHY447263336C0003X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1760477079Medicaid
2115842OtherPK