1053904037 NPI number — DR. ETHAN MICHAEL CORKERY PHARMD

Table of content: DR. ETHAN MICHAEL CORKERY PHARMD (NPI 1053904037)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053904037 NPI number — DR. ETHAN MICHAEL CORKERY PHARMD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CORKERY
Provider First Name:
ETHAN
Provider Middle Name:
MICHAEL
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PHARMD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
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:
1053904037
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/19/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
211 W LEOTA ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NORTH PLATTE
Provider Business Mailing Address State Name:
NE
Provider Business Mailing Address Postal Code:
69101-7792
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
308-532-0310
Provider Business Mailing Address Fax Number:
308-532-2781

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
211 W LEOTA ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NORTH PLATTE
Provider Business Practice Location Address State Name:
NE
Provider Business Practice Location Address Postal Code:
69101-7792
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
308-532-0310
Provider Business Practice Location Address Fax Number:
308-532-2781
Provider Enumeration Date:
02/19/2021

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 183500000X , with the licence number:  16915 , registered in the state of NE ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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