Provider Demographics
NPI:1396092243
Name:CORNELIUS, BRIAN RAYMOND (PHARMD)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:RAYMOND
Last Name:CORNELIUS
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:106 FALCON CT
Mailing Address - Street 2:
Mailing Address - City:EAGLE LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:56024-4497
Mailing Address - Country:US
Mailing Address - Phone:507-341-4049
Mailing Address - Fax:
Practice Address - Street 1:2010 ADAMS ST
Practice Address - Street 2:
Practice Address - City:MANKATO
Practice Address - State:MN
Practice Address - Zip Code:56001-6817
Practice Address - Country:US
Practice Address - Phone:507-625-7565
Practice Address - Fax:507-625-2606
Is Sole Proprietor?:No
Enumeration Date:2012-08-09
Last Update Date:2012-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN120520183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist