=====================================================
General NPI Number Information
=====================================================
NPI Number | 1538101167
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CORKREANS THE PHARMACIST INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/11/2006
-----------------------------------------------------
Last Update Date | 07/20/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 32713 COUNTY ROAD 473
-----------------------------------------------------
City | LEESBURG
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34788-8856
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 352-742-8080
-----------------------------------------------------
Fax | 352-742-9292
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 32713 COUNTY ROAD 473
-----------------------------------------------------
City | LEESBURG
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34788-8856
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 352-742-8080
-----------------------------------------------------
Fax | 352-742-9292
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHARMACIST/OWNER
-----------------------------------------------------
Name | MR. JAMES ALAN CORKREAN
-----------------------------------------------------
Credential | RPH
-----------------------------------------------------
Telephone | 352-742-8080
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM1300X
-----------------------------------------------------
Taxonomy Name | Multi-Specialty Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QP2300X
-----------------------------------------------------
Taxonomy Name | Primary Care Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 261QU0200X
-----------------------------------------------------
Taxonomy Name | Urgent Care Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #5
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------