Provider Demographics
NPI:1093820656
Name:WALKERS COTTAGE APOTHECARY INC
Entity Type:Organization
Organization Name:WALKERS COTTAGE APOTHECARY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:LEON
Authorized Official - Middle Name:G
Authorized Official - Last Name:WALKER
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:773-924-6723
Mailing Address - Street 1:654 E 47TH STREET
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60653-4224
Mailing Address - Country:US
Mailing Address - Phone:773-924-6723
Mailing Address - Fax:773-924-6817
Practice Address - Street 1:654 E 47TH STREET
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60653-4224
Practice Address - Country:US
Practice Address - Phone:773-924-6723
Practice Address - Fax:773-924-6817
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
1438248OtherNCPDP
IL=========001Medicaid
1438248OtherNCPDP