Provider Demographics
NPI:1134345457
Name:CORNER DRUG STORE OF WAHPETON INC
Entity type:Organization
Organization Name:CORNER DRUG STORE OF WAHPETON INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST IN CHARGE
Authorized Official - Prefix:
Authorized Official - First Name:LUCAS
Authorized Official - Middle Name:BRADLEY
Authorized Official - Last Name:GLARUM
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:701-642-6223
Mailing Address - Street 1:619 DAKOTA AVE
Mailing Address - Street 2:
Mailing Address - City:WAHPETON
Mailing Address - State:ND
Mailing Address - Zip Code:58075-4325
Mailing Address - Country:US
Mailing Address - Phone:701-642-6223
Mailing Address - Fax:701-642-8839
Practice Address - Street 1:619 DAKOTA AVE
Practice Address - Street 2:
Practice Address - City:WAHPETON
Practice Address - State:ND
Practice Address - Zip Code:58075-4325
Practice Address - Country:US
Practice Address - Phone:701-642-6223
Practice Address - Fax:701-642-8839
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-17
Last Update Date:2024-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X
NDPHAR153336L0003X, 3336S0011X
ND153336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN701260XMedicaid
ND20159Medicaid
3501803OtherNABP
ND20159Medicaid