Healthcare Provider Details

I. General information

NPI: 1265597272
Provider Name (Legal Business Name): CORNELL PHARMACY, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/27/2006
Last Update Date: 10/04/2024
Certification Date: 10/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 MAIN ST
CORNELL WI
54732-8384
US

IV. Provider business mailing address

PO BOX 554 300 MAIN ST.
CORNELL WI
54732-0554
US

V. Phone/Fax

Practice location:
  • Phone: 715-239-6453
  • Fax: 715-239-6078
Mailing address:
  • Phone: 715-239-6453
  • Fax: 715-239-6078

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number8857-42
License Number StateWI

VIII. Authorized Official

Name: MR. JOSHUA J. PROHASKA
Title or Position: OWNER
Credential:
Phone: 715-239-6453