Healthcare Provider Details

I. General information

NPI: 1922948579
Provider Name (Legal Business Name): BENJAMIN COTTONGIM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/31/2026
Last Update Date: 03/31/2026
Certification Date: 03/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1808 ROSETTE WAY
INDIANAPOLIS IN
46202-1371
US

IV. Provider business mailing address

1808 ROSETTE WAY
INDIANAPOLIS IN
46202-1371
US

V. Phone/Fax

Practice location:
  • Phone: 317-441-0979
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835C0205X
TaxonomyCritical Care Pharmacist
License Number26025502A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: