Healthcare Provider Details

I. General information

NPI: 1689321028
Provider Name (Legal Business Name): SUREKHA KOTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/06/2022
Last Update Date: 03/06/2022
Certification Date: 03/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

123 NASHUA RD
LONDONDERRY NH
03053-3453
US

IV. Provider business mailing address

19 BOURNE DR
BEDFORD NH
03110-6849
US

V. Phone/Fax

Practice location:
  • Phone: 603-437-8100
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License NumberCPHT-123974
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: