1487194874 NPI number — COTTRILLS PHARMACY INC

Table of content: (NPI 1487194874)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1487194874 NPI number — COTTRILLS PHARMACY INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COTTRILLS PHARMACY INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
COTTRILLS PHARMACY, INC.
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1487194874
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/06/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4919 ELLICOTT RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ORCHARD PARK
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
14127-3357
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
716-508-8481
Provider Business Mailing Address Fax Number:
716-508-8482

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4919 ELLICOTT RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ORCHARD PARK
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
14127-3357
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
716-508-8481
Provider Business Practice Location Address Fax Number:
716-508-8482
Provider Enumeration Date:
03/03/2017

Additional Information

Authorized Official

Authorized Official Last Name:
MELLERSKI
Authorized Official First Name:
ERIN
Authorized Official Middle Name:
E.
Authorized Official Title or Position:
CHIEF CLINICAL OFFICER/SVP
Authorized Official Telephone Number:
716-508-8481

Provider Taxonomy Codes

  • Taxonomy code: 3336C0003X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 3336H0001X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336S0011X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0790443 01 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0226826 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1027458620002 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 320287 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".
  • Identifier: 04789873 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 7100436300 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1487194874 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 250428333 , issued by the state of ( DE ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1487194874 , issued by the state of ( MT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1487194874 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2168227 . This is a "PK" identifier . This identifiers is of the category "OTHER".




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