Provider Demographics
NPI:1942350269
Name:THE CORNER DRUG STORE
Entity Type:Organization
Organization Name:THE CORNER DRUG STORE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GIL
Authorized Official - Middle Name:
Authorized Official - Last Name:BIRCH
Authorized Official - Suffix:
Authorized Official - Credentials:PHRM
Authorized Official - Phone:318-255-3318
Mailing Address - Street 1:120 S TRENTON ST
Mailing Address - Street 2:
Mailing Address - City:RUSTON
Mailing Address - State:LA
Mailing Address - Zip Code:71270-4473
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:120 S TRENTON ST
Practice Address - Street 2:
Practice Address - City:RUSTON
Practice Address - State:LA
Practice Address - Zip Code:71270-4473
Practice Address - Country:US
Practice Address - Phone:318-255-3318
Practice Address - Fax:318-255-2146
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA002317333600000X
3336C0003X, 3336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered333600000XSuppliersPharmacy
Not Answered3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Not Answered3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1259110Medicaid
1910593OtherOTHER ID NUMBER-COMMERCIAL NUMBER