Healthcare Provider Details

I. General information

NPI: 1326451261
Provider Name (Legal Business Name): MISS SUJATHA KOTARU
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/09/2014
Last Update Date: 06/09/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1003 PULASKI HWY
HAVRE DE GRACE MD
21078-2603
US

IV. Provider business mailing address

165 HAUT BRION AVE
NEWARK DE
19702-4537
US

V. Phone/Fax

Practice location:
  • Phone: 410-939-1140
  • Fax:
Mailing address:
  • Phone: 302-836-3699
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number17824
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: