MEDICARE: CORNELLS PHARMACY LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	333600000X	Pharmacy
2	3336C0003X	Community/Retail Pharmacy	021274650	OH

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	3669554	OTHER		NCPDP PROVIDER IDENTIFICATION NUMBER
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1023014255
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CORNELLS PHARMACY LLC

Provider Business Mailing Address
First Line	:	PO BOX 645
Second Line	:
City	:	SHELBY
State	:	OH
Zip	:	44875-0645
Country	:	US
Telephone Number	:	419-347-2033
Fax Number	:	419-347-2053

Provider Business Practice Location Address
First Line	:	140 MANSFIELD AVE
Second Line	:
City	:	SHELBY
State	:	OH
Zip	:	44875-1833
Country	:	US
Telephone Number	:	419-347-2033
Fax Number	:	419-347-2053

Authorized Official
Title or Position	:	MANAGER
Name	:	MARCIA TRISKA
Credential	:	RPH
Telephone Number	:	419-374-2033

Provider Enumeration Date	:	06/22/2005
Last Update Date	:	03/08/2011

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