Provider Demographics
NPI:1922031392
Name:CORNER DRUG STORE
Entity Type:Organization
Organization Name:CORNER DRUG STORE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:MR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:A
Authorized Official - Last Name:GERACHE
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:601-636-2756
Mailing Address - Street 1:1123 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:VICKSBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39183-2959
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1123 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:VICKSBURG
Practice Address - State:MS
Practice Address - Zip Code:39183-2959
Practice Address - Country:US
Practice Address - Phone:601-636-2756
Practice Address - Fax:601-638-0071
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS00274183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00031101Medicaid