Healthcare Provider Details

I. General information

NPI: 1447981378
Provider Name (Legal Business Name): TIMOTHY KOTSUBA PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/21/2022
Last Update Date: 06/21/2022
Certification Date: 06/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1405 70TH ST APT 4B
BROOKLYN NY
11228-1716
US

IV. Provider business mailing address

1405 70TH ST APT 4B
BROOKLYN NY
11228-1716
US

V. Phone/Fax

Practice location:
  • Phone: 347-265-9735
  • Fax:
Mailing address:
  • Phone: 347-265-9735
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberI068759-01
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number28RI04230800
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: