Provider Demographics
NPI:1952909632
Name:CORDANT PHARMACY ILLINOIS, LLC
Entity Type:Organization
Organization Name:CORDANT PHARMACY ILLINOIS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE ASSISTANT
Authorized Official - Prefix:
Authorized Official - First Name:FARA
Authorized Official - Middle Name:
Authorized Official - Last Name:TIPPIT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:720-272-3535
Mailing Address - Street 1:1620 W NORTHWEST HWY STE 100
Mailing Address - Street 2:
Mailing Address - City:GRAPEVINE
Mailing Address - State:TX
Mailing Address - Zip Code:76051-3219
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8623 W BRYN MAWR AVE STE 504
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60631-3525
Practice Address - Country:US
Practice Address - Phone:872-264-5673
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CORDANT PHARMACY ILLINOIS, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-10-14
Last Update Date:2020-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL054.021576OtherILLINOIS BOARD OF PHARMACY