=====================================================
General NPI Number Information
=====================================================
NPI Number | 1215297890
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THE CORNER APOTHECARY, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/17/2012
-----------------------------------------------------
Last Update Date | 11/25/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2 S MAIN ST
-----------------------------------------------------
City | CAMDEN
-----------------------------------------------------
State | DE
-----------------------------------------------------
Zip | 19934-1319
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 302-387-1590
-----------------------------------------------------
Fax | 302-387-1744
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 402
-----------------------------------------------------
City | CAMDEN
-----------------------------------------------------
State | DE
-----------------------------------------------------
Zip | 19934-0402
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 302-387-1590
-----------------------------------------------------
Fax | 302-387-1744
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/CEO
-----------------------------------------------------
Name | SANDRA ZARAGOZA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 302-387-1590
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0004X
-----------------------------------------------------
Taxonomy Name | Compounding Pharmacy
-----------------------------------------------------
License Number | A30000931
-----------------------------------------------------
License Number State | DE
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | A3-0000931
-----------------------------------------------------
License Number State | DE
-----------------------------------------------------