Healthcare Provider Details

I. General information

NPI: 1730791005
Provider Name (Legal Business Name): KENDALL KOTTER PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/18/2020
Last Update Date: 01/07/2023
Certification Date: 01/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 E JACKSON ST
MACOMB IL
61455-2307
US

IV. Provider business mailing address

300 E JACKSON ST
MACOMB IL
61455-2307
US

V. Phone/Fax

Practice location:
  • Phone: 309-837-2436
  • Fax:
Mailing address:
  • Phone: 309-837-2436
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number051.303181
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: