Healthcare Provider Details

I. General information

NPI: 1245748508
Provider Name (Legal Business Name): RADHIKA KOTA R.PH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/19/2018
Last Update Date: 01/19/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2128 NW 156TH ST UNIT 31
CLIVE IA
50325-7970
US

IV. Provider business mailing address

2128 NW 156TH ST UNIT 31
CLIVE IA
50325-7970
US

V. Phone/Fax

Practice location:
  • Phone: 267-241-9741
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number28RI03181400
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: