Provider Demographics
NPI:1376928853
Name:PATTERSON, CORY (PHARMD, RPH)
Entity Type:Individual
Prefix:
First Name:CORY
Middle Name:
Last Name:PATTERSON
Suffix:
Gender:M
Credentials:PHARMD, RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2104 HACKBERRY RD
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61704-2788
Mailing Address - Country:US
Mailing Address - Phone:309-531-5650
Mailing Address - Fax:309-661-8272
Practice Address - Street 1:2104 HACKBERRY RD
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61704-2788
Practice Address - Country:US
Practice Address - Phone:309-531-5650
Practice Address - Fax:309-661-8272
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-24
Last Update Date:2015-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051.291519183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist