Provider Demographics
NPI:1053410977
Name:COTTRELL, CHARLES DANIEL (RPH)
Entity type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:DANIEL
Last Name:COTTRELL
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2110 WILDWOOD DR
Mailing Address - Street 2:
Mailing Address - City:BREWTON
Mailing Address - State:AL
Mailing Address - Zip Code:36426-2938
Mailing Address - Country:US
Mailing Address - Phone:251-867-5454
Mailing Address - Fax:251-867-6117
Practice Address - Street 1:1121 BELLEVILLE AVE
Practice Address - Street 2:
Practice Address - City:BREWTON
Practice Address - State:AL
Practice Address - Zip Code:36426-1500
Practice Address - Country:US
Practice Address - Phone:251-867-5454
Practice Address - Fax:251-867-6117
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL9836183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL0101775OtherNABP PHARMACY #
AL10000228Medicaid
AL10000228Medicaid