1396220828 NPI number — DR. EDMUND J CORDOVA RPH, PHARMD

Table of content: DR. EDMUND J CORDOVA RPH, PHARMD (NPI 1396220828)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396220828 NPI number — DR. EDMUND J CORDOVA RPH, PHARMD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CORDOVA
Provider First Name:
EDMUND
Provider Middle Name:
J
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
RPH, PHARMD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
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:
1396220828
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/08/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7317 BAYBERRY LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DARIEN
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60561-3709
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
630-715-1767
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1901 W 22ND ST FL 1
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OAK BROOK
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60523-1785
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
630-928-0220
Provider Business Practice Location Address Fax Number:
630-928-0567
Provider Enumeration Date:
10/01/2018

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 183500000X , with the licence number:  051.301590 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1835P0018X , with the licence number: 051.301590 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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