Provider Demographics
NPI:1902989809
Name:THE CORNER DRUGSTORE INC
Entity Type:Organization
Organization Name:THE CORNER DRUGSTORE INC
Other - Org Name:STANDARD DRUG
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:GERALD
Authorized Official - Middle Name:
Authorized Official - Last Name:ROBERTS
Authorized Official - Suffix:
Authorized Official - Credentials:RPH CF
Authorized Official - Phone:636-946-6557
Mailing Address - Street 1:2 CHARLESTOWNE PLZ
Mailing Address - Street 2:
Mailing Address - City:SAINT CHARLES
Mailing Address - State:MO
Mailing Address - Zip Code:63303-6376
Mailing Address - Country:US
Mailing Address - Phone:636-441-1055
Mailing Address - Fax:
Practice Address - Street 1:2 CHARLESTOWNE PLZ
Practice Address - Street 2:
Practice Address - City:SAINT CHARLES
Practice Address - State:MO
Practice Address - Zip Code:63303-6376
Practice Address - Country:US
Practice Address - Phone:636-441-1055
Practice Address - Fax:636-922-0049
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-23
Last Update Date:2008-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO004713332B00000X
333600000X, 3336C0003X, 3336C0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2603442OtherOTHER ID NUMBER-COMMERCIAL NUMBER
2603442OtherOTHER ID NUMBER-COMMERCIAL NUMBER