Healthcare Provider Details

I. General information

NPI: 1134467525
Provider Name (Legal Business Name): ANGELA KUTANJAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/21/2013
Last Update Date: 01/21/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 E HALLANDALE BEACH BLVD
HALLANDALE BEACH FL
33009-4617
US

IV. Provider business mailing address

3901 S OCEAN DR
HOLLYWOOD FL
33019-3016
US

V. Phone/Fax

Practice location:
  • Phone: 954-454-8825
  • Fax:
Mailing address:
  • Phone: 954-703-0758
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberPS46912
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: