Healthcare Provider Details

I. General information

NPI: 1790380582
Provider Name (Legal Business Name): KELLY ANN KOTROZO I
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/01/2020
Last Update Date: 12/01/2020
Certification Date: 12/01/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11240 PERRY HWY
WEXFORD PA
15090-8332
US

IV. Provider business mailing address

11240 PERRY HWY
WEXFORD PA
15090-8332
US

V. Phone/Fax

Practice location:
  • Phone: 724-935-7890
  • Fax: 724-935-7895
Mailing address:
  • Phone: 724-935-7890
  • Fax: 724-935-7895

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberRP038180L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: