=====================================================
General NPI Number Information
=====================================================
NPI Number | 1043546799
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CORNERSTONE PHARMACY OF BELLA VISTA LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/29/2009
-----------------------------------------------------
Last Update Date | 12/17/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1 MERCY WAY STE 50
-----------------------------------------------------
City | BELLA VISTA
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72714-3000
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 479-876-6200
-----------------------------------------------------
Fax | 479-876-2232
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1 MERCY WAY STE 50
-----------------------------------------------------
City | BELLA VISTA
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72714-3000
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 479-876-6200
-----------------------------------------------------
Fax | 479-876-2232
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO, OWNER
-----------------------------------------------------
Name | JAMES GRAHAM
-----------------------------------------------------
Credential | PH.D., PHARM. D
-----------------------------------------------------
Telephone | 479-876-6200
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0004X
-----------------------------------------------------
Taxonomy Name | Compounding Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 333600000X
-----------------------------------------------------
Taxonomy Name | Pharmacy
-----------------------------------------------------
License Number | AR20616
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------