Provider Demographics
NPI:1043598295
Name:ROTELLA, CHARLES (RPH)
Entity Type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:
Last Name:ROTELLA
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:591 BURNSIDE AVE
Mailing Address - Street 2:
Mailing Address - City:INWOOD
Mailing Address - State:NY
Mailing Address - Zip Code:11096-1300
Mailing Address - Country:US
Mailing Address - Phone:516-371-2828
Mailing Address - Fax:516-371-7814
Practice Address - Street 1:591 BURNSIDE AVE
Practice Address - Street 2:
Practice Address - City:INWOOD
Practice Address - State:NY
Practice Address - Zip Code:11096-1300
Practice Address - Country:US
Practice Address - Phone:516-371-2828
Practice Address - Fax:516-371-7814
Is Sole Proprietor?:No
Enumeration Date:2011-07-21
Last Update Date:2011-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYI033531183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist