Provider Demographics
NPI:1841585403
Name:CORNERSTONE DISTRIBUTION LLC
Entity Type:Organization
Organization Name:CORNERSTONE DISTRIBUTION LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:MRS
Authorized Official - First Name:TAMMIE
Authorized Official - Middle Name:R
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:MSM
Authorized Official - Phone:317-755-2731
Mailing Address - Street 1:6214 MORENCI TRL
Mailing Address - Street 2:SUITE 100
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46268-4871
Mailing Address - Country:US
Mailing Address - Phone:317-755-2731
Mailing Address - Fax:317-755-2657
Practice Address - Street 1:6214 MORENCI TRL
Practice Address - Street 2:SUITE 100
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46268-4871
Practice Address - Country:US
Practice Address - Phone:317-755-2731
Practice Address - Fax:317-755-2657
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-12
Last Update Date:2013-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201020240AMedicaid