Healthcare Provider Details

I. General information

NPI: 1023498508
Provider Name (Legal Business Name): TANYA KOTENOGLOU
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/01/2015
Last Update Date: 06/01/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6375 LIBRARY RD
SOUTH PARK PA
15129-8502
US

IV. Provider business mailing address

106 KATHY ANN LN
MC MURRAY PA
15317-3200
US

V. Phone/Fax

Practice location:
  • Phone: 412-831-8350
  • Fax:
Mailing address:
  • Phone: 412-217-9120
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberRP044124R
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: