=====================================================
General NPI Number Information
=====================================================
NPI Number | 1518038694
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CORNER PHARMACY CORPORATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/12/2006
-----------------------------------------------------
Last Update Date | 07/14/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2011 COYNE ST
-----------------------------------------------------
City | HONOLULU
-----------------------------------------------------
State | HI
-----------------------------------------------------
Zip | 96826-1334
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 808-946-0064
-----------------------------------------------------
Fax | 808-949-7131
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2011 COYNE ST
-----------------------------------------------------
City | HONOLULU
-----------------------------------------------------
State | HI
-----------------------------------------------------
Zip | 96826-1334
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 808-946-0064
-----------------------------------------------------
Fax | 808-949-7131
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MR. CARL PHILLIP MUDRICK
-----------------------------------------------------
Credential | R.PH.
-----------------------------------------------------
Telephone | 808-946-0064
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | PHY685
-----------------------------------------------------
License Number State | HI
-----------------------------------------------------