1043546799 NPI number — CORNERSTONE PHARMACY OF BELLA VISTA LLC

Table of content: (NPI 1043546799)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1043546799 NPI number — CORNERSTONE PHARMACY OF BELLA VISTA LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CORNERSTONE PHARMACY OF BELLA VISTA LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
CORNERSTONE PHARMACY OF BELLA VISTA, LLC
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1043546799
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/17/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1 MERCY WAY
Provider Second Line Business Mailing Address:
STE 50
Provider Business Mailing Address City Name:
BELLA VISTA
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72714-3000
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
479-876-6200
Provider Business Mailing Address Fax Number:
479-876-2232

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1 MERCY WAY STE 50
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BELLA VISTA
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72714-3000
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
479-876-6200
Provider Business Practice Location Address Fax Number:
479-876-2232
Provider Enumeration Date:
10/29/2009

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
GRAHAM
Authorized Official First Name:
JAMES
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO, OWNER
Authorized Official Telephone Number:
479-876-6200

Provider Taxonomy Codes

  • Taxonomy code: 333600000X , with the licence number:  AR20616 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 3336C0003X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0004X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 2122774 . This is a "PK" identifier . This identifiers is of the category "OTHER".
  • Identifier: 183982407 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".