Provider Demographics
NPI:1720081326
Name:CORDOVA DRUG CO
Entity type:Organization
Organization Name:CORDOVA DRUG CO
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:OBRIEN
Authorized Official - Suffix:
Authorized Official - Credentials:BS PHARMACY
Authorized Official - Phone:907-424-3246
Mailing Address - Street 1:PO BOX 220
Mailing Address - Street 2:
Mailing Address - City:CORDOVA
Mailing Address - State:AK
Mailing Address - Zip Code:99574-0220
Mailing Address - Country:US
Mailing Address - Phone:907-424-3246
Mailing Address - Fax:907-424-3245
Practice Address - Street 1:516 1ST STREET
Practice Address - Street 2:
Practice Address - City:CORDOVA
Practice Address - State:AK
Practice Address - Zip Code:99574-0220
Practice Address - Country:US
Practice Address - Phone:907-424-3246
Practice Address - Fax:907-424-3245
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-05-27
Last Update Date:2016-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
AKPHAR93336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKMS8109Medicaid
1996415OtherPK
AKPH0009Medicaid