Healthcare Provider Details

I. General information

NPI: 1821098278
Provider Name (Legal Business Name): MARK MICHAEL COTA
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 07/28/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 W 3RD ST
RED WING MN
55066-2310
US

IV. Provider business mailing address

2346 PINEVIEW CT
RED WING MN
55066-4041
US

V. Phone/Fax

Practice location:
  • Phone: 651-388-3521
  • Fax: 651-388-8059
Mailing address:
  • Phone: 651-388-5714
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number115215-1
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: