Provider Demographics
NPI:1922191360
Name:CORNER DRUG OF DURANT INC
Entity Type:Organization
Organization Name:CORNER DRUG OF DURANT INC
Other - Org Name:CORNER DRUG OF DURANT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER AND CHIEF PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:CLARK
Authorized Official - Middle Name:
Authorized Official - Last Name:NORTHCUTT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:580-924-4444
Mailing Address - Street 1:1005 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:DURANT
Mailing Address - State:OK
Mailing Address - Zip Code:74701-5038
Mailing Address - Country:US
Mailing Address - Phone:580-924-4444
Mailing Address - Fax:580-924-0018
Practice Address - Street 1:1005 W MAIN ST
Practice Address - Street 2:
Practice Address - City:DURANT
Practice Address - State:OK
Practice Address - Zip Code:74701-5038
Practice Address - Country:US
Practice Address - Phone:580-924-4444
Practice Address - Fax:580-924-0018
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-30
Last Update Date:2015-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2714483336C0003X
3336L0003X, 3336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100244720AMedicaid
OK100244720BMedicaid
2072725OtherPK
OK100244720AMedicaid