=====================================================
General NPI Number Information
=====================================================
NPI Number | 1023362464
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CORNERSTONE PHARMACY JFK, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/07/2012
-----------------------------------------------------
Last Update Date | 11/07/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5328 JOHN F KENNEDY BLVD
-----------------------------------------------------
City | NORTH LITTLE ROCK
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72116-6704
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 501-223-2224
-----------------------------------------------------
Fax | 866-399-5514
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 15 CHAMBORD LN
-----------------------------------------------------
City | LITTLE ROCK
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72223-5946
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 501-223-2224
-----------------------------------------------------
Fax | 866-399-5514
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PARTNER/OWNER
-----------------------------------------------------
Name | KENNY HARRISON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 501-580-1895
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | AR20689
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------