Healthcare Provider Details

I. General information

NPI: 1114557493
Provider Name (Legal Business Name): WILLIAM MATTHEW CORNELIUS PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/25/2020
Last Update Date: 01/25/2020
Certification Date: 01/25/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14889 N US HIGHWAY 25 E STE A
CORBIN KY
40701-6196
US

IV. Provider business mailing address

204 SUBLIMITY SCHOOL RD
LONDON KY
40744-8176
US

V. Phone/Fax

Practice location:
  • Phone: 606-528-7211
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License Number017737
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: