Provider Demographics
NPI:1609921253
Name:COTTAGE PHARMACY & SURGICAL INC
Entity Type:Organization
Organization Name:COTTAGE PHARMACY & SURGICAL INC
Other - Org Name:COTTAGE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RAJENDRAPRASAD
Authorized Official - Middle Name:
Authorized Official - Last Name:VENIGALLA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-399-8677
Mailing Address - Street 1:8285 JERICHO TPKE
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:NY
Mailing Address - Zip Code:11797-1807
Mailing Address - Country:US
Mailing Address - Phone:516-367-9030
Mailing Address - Fax:516-367-4443
Practice Address - Street 1:8285 JERICHO TPKE
Practice Address - Street 2:
Practice Address - City:WOODBURY
Practice Address - State:NY
Practice Address - Zip Code:11797-1807
Practice Address - Country:US
Practice Address - Phone:516-367-9030
Practice Address - Fax:516-367-4443
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-24
Last Update Date:2017-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
NY0308813336C0003X
NHNR12683336C0003X
WAPHNR.FO.604303913336C0003X
CTPCN.00024773336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2158179OtherPK
NY03564981Medicaid
4506760002Medicare NSC
NY4506760002Medicare NSC