Provider Demographics
NPI:1144385576
Name:MASCOT PHARMACY INC
Entity Type:Organization
Organization Name:MASCOT PHARMACY INC
Other - Org Name:MEDICINE SHOPPE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:MARIA
Authorized Official - Middle Name:L
Authorized Official - Last Name:COSTA
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:847-698-3323
Mailing Address - Street 1:110 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:PARK RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60068-4030
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:110 MAIN ST
Practice Address - Street 2:
Practice Address - City:PARK RIDGE
Practice Address - State:IL
Practice Address - Zip Code:60068-4030
Practice Address - Country:US
Practice Address - Phone:847-698-3323
Practice Address - Fax:847-698-4112
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-26
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336C0003X
IL0540144033336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
1425950OtherOTHER ID NUMBER-COMMERCIAL NUMBER
1425950OtherOTHER ID NUMBER-COMMERCIAL NUMBER
IL=========001Medicaid
ILBM6897310OtherDEA #