Provider Demographics
NPI:1720143258
Name:CORNER PHARMACY
Entity Type:Organization
Organization Name:CORNER PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:MARTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:RUBIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-599-2771
Mailing Address - Street 1:166 DIVISION AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11211-7108
Mailing Address - Country:US
Mailing Address - Phone:718-599-2771
Mailing Address - Fax:718-599-1474
Practice Address - Street 1:166 DIVISION AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11211-7108
Practice Address - Country:US
Practice Address - Phone:718-599-2771
Practice Address - Fax:718-599-1474
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-26
Last Update Date:2010-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY040080 13336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01639385Medicaid
NY01639385Medicaid