=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790316354
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DYANA KOTANI
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/31/2020
-----------------------------------------------------
Last Update Date | 01/31/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4995 HIGHLAND RD
-----------------------------------------------------
City | WATERFORD
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48328-1143
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-674-2261
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 37792 BLOSSOM LN
-----------------------------------------------------
City | FARMINGTON HILLS
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48331-1734
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-535-4482
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 5302411950
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------