MEDICARE: CORNERSTONE COMPOUNDING PHARMACY INC

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	3336C0003X	Community/Retail Pharmacy	51660	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2142584	OTHER		PK

General Provider Information

NPI Number	:	1700214079
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CORNERSTONE COMPOUNDING PHARMACY INC

Provider Business Mailing Address
First Line	:	1131 N PACIFIC AVE
Second Line	:
City	:	GLENDALE
State	:	CA
Zip	:	91202-2358
Country	:	US
Telephone Number	:	818-550-1522
Fax Number	:	877-245-3137

Provider Business Practice Location Address
First Line	:	1131 N PACIFIC AVE
Second Line	:
City	:	GLENDALE
State	:	CA
Zip	:	91202-2358
Country	:	US
Telephone Number	:	818-550-1522
Fax Number	:	877-245-3137

Authorized Official
Title or Position	:	OPERATIONS
Name	:	DAVIN DEB
Credential	:
Telephone Number	:	818-550-1522

Provider Enumeration Date	:	10/24/2013
Last Update Date	:	12/03/2013

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