Healthcare Provider Details

I. General information

NPI: 1124467824
Provider Name (Legal Business Name): JOSEPH MICHAEL KOTANSKY R PH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/17/2013
Last Update Date: 06/17/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

39000 BOB HOPE DR SUITE K-114
RANCHO MIRAGE CA
92270-3221
US

IV. Provider business mailing address

39000 BOB HOPE DR SUITE K-114
RANCHO MIRAGE CA
92270-3221
US

V. Phone/Fax

Practice location:
  • Phone: 760-773-1219
  • Fax: 760-773-4289
Mailing address:
  • Phone: 760-773-1219
  • Fax: 760-773-4289

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number44576
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: