MEDICARE: ROBERT GATHERCOAL

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist		IL

General Provider Information

NPI Number	:	1902021736
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ROBERT GATHERCOAL

Provider Business Mailing Address
First Line	:	1026 WASHINGTON ST
Second Line	:
City	:	GLENVIEW
State	:	IL
Zip	:	60025-2860
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1340 PATRIOT BLVD
Second Line	:
City	:	GLENVIEW
State	:	IL
Zip	:	60026-7777
Country	:	US
Telephone Number	:	847-657-8691
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/16/2007
Last Update Date	:	07/08/2007

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