Healthcare Provider Details

I. General information

NPI: 1912373911
Provider Name (Legal Business Name): JAE GATCHALIAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/13/2015
Last Update Date: 08/13/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8560 S COTTAGE GROVE AVE
CHICAGO IL
60619-6116
US

IV. Provider business mailing address

701 CHURCHILL DR
NEW LENOX IL
60451-3368
US

V. Phone/Fax

Practice location:
  • Phone: 773-371-8556
  • Fax:
Mailing address:
  • Phone: 815-485-5410
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number051298852
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: