=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609900042
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | EDWIN SCOTT CORNELIUS PHARMD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/16/2007
-----------------------------------------------------
Last Update Date | 12/19/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1433 3RD STREET S.W
-----------------------------------------------------
City | ATTALLA
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 35954-0490
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 256-538-5850
-----------------------------------------------------
Fax | 256-538-1860
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 115 ARROW WOOD LN
-----------------------------------------------------
City | GADSDEN
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 35901-8611
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 256-442-9446
-----------------------------------------------------
Fax | 256-538-5850
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 14587
-----------------------------------------------------
License Number State | AL
-----------------------------------------------------