1265597272 NPI number — CORNELL PHARMACY, INC.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265597272 NPI number — CORNELL PHARMACY, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CORNELL PHARMACY, INC.
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:
CORNELL PHARMACY
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:
1265597272
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 554
Provider Second Line Business Mailing Address:
300 MAIN ST.
Provider Business Mailing Address City Name:
CORNELL
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
54732-0554
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
715-239-6453
Provider Business Mailing Address Fax Number:
715-239-6078

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
300 MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CORNELL
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
54732-8384
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
715-239-6453
Provider Business Practice Location Address Fax Number:
715-239-6078
Provider Enumeration Date:
12/27/2006

Additional Information

Authorized Official

Authorized Official Last Name:
PROHASKA
Authorized Official First Name:
JOSHUA
Authorized Official Middle Name:
J.
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
715-239-6453

Provider Taxonomy Codes

  • Taxonomy code: 3336C0003X , with the licence number:  8857-42 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 8857-42 . This is a "WI STATE ID #" identifier . This identifiers is of the category "OTHER".
  • Identifier: 36228500 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




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