Healthcare Provider Details

I. General information

NPI: 1568532331
Provider Name (Legal Business Name): NICHOLAS KOTAKES LOHSE PHARM. D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/09/2006
Last Update Date: 07/07/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3053 SW MARTIN DOWNS BLVD
PALM CITY FL
34990-2644
US

IV. Provider business mailing address

9652 SW GRANADA CT
PALM CITY FL
34990-5455
US

V. Phone/Fax

Practice location:
  • Phone: 772-288-0105
  • Fax:
Mailing address:
  • Phone: 772-597-4298
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P1200X
TaxonomyPharmacotherapy Pharmacist
License NumberPS0032115
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: