Healthcare Provider Details

I. General information

NPI: 1396871794
Provider Name (Legal Business Name): CAHOKIA PHARMACY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/27/2007
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

817 UPPER CAHOKIA RD
CAHOKIA IL
62206-1211
US

IV. Provider business mailing address

233 HICKORY RDG
BELLEVILLE IL
62223-3443
US

V. Phone/Fax

Practice location:
  • Phone: 618-332-1028
  • Fax: 618-332-7028
Mailing address:
  • Phone: 618-920-0295
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number054009531
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number054009531
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: ENRICO BERTUCCI
Title or Position: OWNER PHARMACIST
Credential: RPH
Phone: 618-332-1028