Healthcare Provider Details

I. General information

NPI: 1528164761
Provider Name (Legal Business Name): ANNETTE CHRISTINE KOSSIFOLOGOS PHARM.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: ANNETTE CHRISTINE ROTELLA PHARM.D.

II. Dates (important events)

Enumeration Date: 09/15/2006
Last Update Date: 11/08/2023
Certification Date: 11/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

EDWARD HINES JR. VAMC, FIFTH AVENUE AND ROOSEVELT ROAD BUILDING 200 ROOM B 128 H, PHARMACY SERVICE (119)
HINES IL
60141
US

IV. Provider business mailing address

211 LONGRIDGE DR
BLOOMINGDALE IL
60108-1417
US

V. Phone/Fax

Practice location:
  • Phone: 708-202-8387
  • Fax:
Mailing address:
  • Phone: 708-421-1772
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number051.291357
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code1835P1200X
TaxonomyPharmacotherapy Pharmacist
License Number051291357
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: