Healthcare Provider Details

I. General information

NPI: 1811857154
Provider Name (Legal Business Name): SIDDHARTH P KOTHARI
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/17/2025
Last Update Date: 11/17/2025
Certification Date: 11/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

106 CELESTINO CT
BLACKWOOD NJ
08012-4435
US

IV. Provider business mailing address

106 CELESTINO CT
BLACKWOOD NJ
08012-4435
US

V. Phone/Fax

Practice location:
  • Phone: 856-651-9036
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number28RI04348100
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: