Provider Demographics
NPI:1669072658
Name:CORNELL, JON DAVID
Entity type:Individual
Prefix:
First Name:JON
Middle Name:DAVID
Last Name:CORNELL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:622 FAIRVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:SIDMAN
Mailing Address - State:PA
Mailing Address - Zip Code:15955-3415
Mailing Address - Country:US
Mailing Address - Phone:814-659-0272
Mailing Address - Fax:
Practice Address - Street 1:150 TOWN CENTRE DR
Practice Address - Street 2:
Practice Address - City:JOHNSTOWN
Practice Address - State:PA
Practice Address - Zip Code:15904-2858
Practice Address - Country:US
Practice Address - Phone:814-266-7009
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-28
Last Update Date:2020-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARP041912L183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist