MEDICARE: MARIA KOOTSIKAS MARIA KOOTSIKAS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1835P0018X	Pharmacist Clinician (PhC)/ Clinical Pharmacy Specialist	35821	CA

General Provider Information

NPI Number	:	1366772816
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARIA KOOTSIKAS MARIA KOOTSIKAS

Provider Business Mailing Address
First Line	:	1502 S. CRESCENT HEIGHTS BLVD
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90035-3816
Country	:	US
Telephone Number	:	323-933-0531
Fax Number	:

Provider Business Practice Location Address
First Line	:	1502 S. CRESCENT HEIGHTS BOULEVARD
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90035-3816
Country	:	US
Telephone Number	:	323-933-0531
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/06/2010
Last Update Date	:	01/06/2010

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