Provider Demographics
NPI:1912373911
Name:GATCHALIAN, JAE
Entity Type:Individual
Prefix:
First Name:JAE
Middle Name:
Last Name:GATCHALIAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:701 CHURCHILL DR
Mailing Address - Street 2:
Mailing Address - City:NEW LENOX
Mailing Address - State:IL
Mailing Address - Zip Code:60451-3368
Mailing Address - Country:US
Mailing Address - Phone:815-485-5410
Mailing Address - Fax:
Practice Address - Street 1:8560 S COTTAGE GROVE AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60619-6116
Practice Address - Country:US
Practice Address - Phone:773-371-8556
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-13
Last Update Date:2015-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051298852183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist