Provider Demographics
NPI:1679699805
Name:AGNIHOTRI, TUSHAR (RPH)
Entity type:Individual
Prefix:
First Name:TUSHAR
Middle Name:
Last Name:AGNIHOTRI
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 1:7852 CHURCHILL ST
Mailing Address - Street 2:
Mailing Address - City:MORTON GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60053-1809
Mailing Address - Country:US
Mailing Address - Phone:847-965-3029
Mailing Address - Fax:847-696-3486
Practice Address - Street 1:1900 S CUMBERLAND AVE
Practice Address - Street 2:
Practice Address - City:PARK RIDGE
Practice Address - State:IL
Practice Address - Zip Code:60068-5235
Practice Address - Country:US
Practice Address - Phone:847-696-3846
Practice Address - Fax:847-696-3486
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist