Healthcare Provider Details

I. General information

NPI: 1710694013
Provider Name (Legal Business Name): JUSTIN KOTOBI
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/04/2022
Last Update Date: 11/04/2022
Certification Date: 11/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8100 WYOMING BLVD NE
ALBUQUERQUE NM
87113-1946
US

IV. Provider business mailing address

9215 BLACK FARM LN NW
ALBUQUERQUE NM
87114-5957
US

V. Phone/Fax

Practice location:
  • Phone: 505-857-9783
  • Fax:
Mailing address:
  • Phone: 505-977-8962
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberRP00000106
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: