Healthcare Provider Details

I. General information

NPI: 1891409744
Provider Name (Legal Business Name): LEILA S KUTUZOVA RPH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/05/2023
Last Update Date: 01/05/2023
Certification Date: 01/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

195 MAIN ST
CHATHAM NJ
07928-2405
US

IV. Provider business mailing address

5 CENTER ST APT 6
CHATHAM NJ
07928-2550
US

V. Phone/Fax

Practice location:
  • Phone: 973-635-6200
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number28RI04179800
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: