Provider Demographics
NPI:1396871794
Name:CAHOKIA PHARMACY INC
Entity type:Organization
Organization Name:CAHOKIA PHARMACY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:ENRICO
Authorized Official - Middle Name:
Authorized Official - Last Name:BERTUCCI
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:618-332-1028
Mailing Address - Street 1:233 HICKORY RDG
Mailing Address - Street 2:
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62223-3443
Mailing Address - Country:US
Mailing Address - Phone:618-920-0295
Mailing Address - Fax:
Practice Address - Street 1:817 UPPER CAHOKIA RD
Practice Address - Street 2:
Practice Address - City:CAHOKIA
Practice Address - State:IL
Practice Address - Zip Code:62206-1211
Practice Address - Country:US
Practice Address - Phone:618-332-1028
Practice Address - Fax:618-332-7028
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-27
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL054009531333600000X, 332B00000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
1456676OtherOTHER ID NUMBER-COMMERCIAL NUMBER
ILBC1757737OtherDEA #
IL=========6220601OtherIL HFS PAYEE ID
IL=========001Medicaid
IL=========6220601OtherIL HFS PAYEE ID