Healthcare Provider Details

I. General information

NPI: 1396376885
Provider Name (Legal Business Name): BHAVESHKUMAR KOTHARI
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/03/2020
Last Update Date: 02/03/2020
Certification Date: 02/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

39350 9 MILE RD
NORTHVILLE MI
48167-9164
US

IV. Provider business mailing address

39350 9 MILE RD
NORTHVILLE MI
48167-9164
US

V. Phone/Fax

Practice location:
  • Phone: 248-735-6081
  • Fax: 248-349-7115
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number5302039246
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: