What running a pharmacy chain taught me about building companies

I spent nine years at Big A Drug Stores, starting as Pharmacy Operations Manager in 1999 and finishing as Senior Vice President of Operations in 2008. After that I spent four years at JCA working in long-term care, on the administration and operations side of facilities that dispense to residents who cannot walk into a store.

I founded Cornerstone Health Group in 2013 and co-founded Guided Healthcare in 2022. Almost everything I do at either company traces back to something I learned counting pills and reconciling invoices. Here are the parts that carried over.

Margin lives in purchasing

A pharmacy does not control what it gets paid. Reimbursement is set by payers and PBMs, and the price on the shelf for front-end goods is set by whoever is across the street. What a pharmacy controls is what it pays.

At Big A, the difference between a good year and a bad one was almost never the top line. It was the buy. A few points on generics, a better rebate schedule with a wholesaler, catching a contract that had quietly expired and reverted to list. Those were the numbers that moved the P&L, and they moved it for every store at once.

Cornerstone is that lesson turned into a company. Pharmacy groups, buying groups and small facilities cannot negotiate like a chain, so we aggregate their demand and negotiate for them. It is the purchasing department I used to run, offered to operators who do not have one.

Trust lives in never shipping what you can't account for

In a pharmacy, inventory is not an accounting abstraction. Every unit of a controlled substance has to be counted, and the count has to match the paper, and the paper has to match the order, and if any of that is off there are people whose job is to ask why.

I ran those counts for years. What they teach you is that trust in a regulated business is not a feeling. It is a reconciliation. A customer trusts you because the lot number on the carton matches the certificate, the case count matches the packing list and the invoice matches the quote.

At Cornerstone we do not ship product we cannot trace to a factory and a lot. We do not quote product we have not confirmed exists. When a deal requires a drug license we do not hold, we bring in a licensed pharmaceutical or surgical supply partner rather than pretend. Every one of those rules came from a count sheet.

Regulated industries reward boring discipline

The pharmacy business is not glamorous. The work is procedures, logs, audits, licenses that expire on different schedules, and inspectors who show up when they show up. Operators who treated that as a burden struggled. Operators who treated it as the job did fine.

Long-term care was the same, more so. At JCA the residents depended on the medication cart arriving on time with the right contents, every shift, with no one watching except the people who would be harmed if it failed.

When I look at a new business now, I look for where the discipline has to live. In supply, it is lot control and documentation. In telehealth, it is the chain from symptom to prescriber to pharmacy to follow-up, and whether each step is logged. Companies that get the boring part right have room to make mistakes elsewhere. Companies that skip it do not.

Hire for the back room

The pharmacy counter gets the attention. The back room is where the business lives: the technician who catches the wrong NDC on the order, the bookkeeper who notices the wholesaler double-billed, the receiver who refuses a short pallet.

At Big A I learned that one careful person in receiving was worth more than a second salesperson. I still hire that way. At Cornerstone the operations manager and the people doing data entry are the ones who protect the margin. At Guided, the people building the workflow that routes a lab result to the right clinician matter more than anyone who talks about the workflow.

Why I treat a clinical platform like an ERP

Guided Healthcare is a direct-to-consumer healthcare company. People sometimes describe that as a consumer app. I think of it as an enterprise resource planning system that happens to have patients in it.

A pharmacy chain runs on an ERP whether it calls it that or not. Orders come in, inventory moves, a licensed person signs off, a record is kept, money settles. Telehealth is the same loop with different objects: a patient reports symptoms, a clinician reviews, a lab is ordered, a prescription is written, a pharmacy fills it, a follow-up is scheduled. If any step is not tracked, the loop breaks and nobody knows until a patient calls.

So at Guided we built the operating layer first and the brands on top of it. The platform recruits and qualifies clinicians, connects them to patients and coordinates the ongoing treatment, with each step recorded. UniquelyMe, our women's health brand, sits on it. Other brands can sit on it too. That is not a product idea I had in a meeting. It is how a chain of pharmacies already works, applied to a kind of care that did not exist when I started.

What did not carry over

Not everything transferred. Retail pharmacy taught me to think in stores and districts, and distribution does not work that way. Long-term care taught me patience with slow institutional buyers, and consumer healthcare has none of that patience. I had to unlearn some things.

But the core held. Buy well. Count everything. Do the boring part. Hire the people who notice. Build the system before the storefront. I have not found a business in healthcare where those five fail.