Provider Demographics
NPI:1770597650
Name:CORNELL, DAN E (RPH)
Entity type:Individual
Prefix:
First Name:DAN
Middle Name:E
Last Name:CORNELL
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13300 N OLD NUMBER 7
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65202-7644
Mailing Address - Country:US
Mailing Address - Phone:573-256-5071
Mailing Address - Fax:
Practice Address - Street 1:1506 E BROADWAY
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65201-8078
Practice Address - Country:US
Practice Address - Phone:573-449-5366
Practice Address - Fax:573-443-7938
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO29850183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist