Provider Demographics
NPI:1821157694
Name:COTTAGE CLINIC PHARMACY, INC.
Entity Type:Organization
Organization Name:COTTAGE CLINIC PHARMACY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT & PHARMACIST-IN-CHARGE
Authorized Official - Prefix:MR
Authorized Official - First Name:VISHNU
Authorized Official - Middle Name:U
Authorized Official - Last Name:PATEL
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:773-651-3535
Mailing Address - Street 1:8055 S COTTAGE GROVE AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60619-4003
Mailing Address - Country:US
Mailing Address - Phone:773-651-3535
Mailing Address - Fax:773-651-8968
Practice Address - Street 1:8055 S COTTAGE GROVE AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60619-4003
Practice Address - Country:US
Practice Address - Phone:773-651-3535
Practice Address - Fax:773-651-8968
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-07
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========001Medicaid