Provider Demographics
NPI:1073990768
Name:KOSYAK, TATIANA E (RPH, CPH)
Entity Type:Individual
Prefix:
First Name:TATIANA
Middle Name:E
Last Name:KOSYAK
Suffix:
Gender:F
Credentials:RPH, CPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:38 LAUREL RIDGE BREAK
Mailing Address - Street 2:
Mailing Address - City:ORMOND BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32174
Mailing Address - Country:US
Mailing Address - Phone:386-235-8760
Mailing Address - Fax:
Practice Address - Street 1:38 LAUREL RIDGE BREAK
Practice Address - Street 2:
Practice Address - City:ORMOND BEACH
Practice Address - State:FL
Practice Address - Zip Code:32174
Practice Address - Country:US
Practice Address - Phone:386-235-8760
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-05-01
Last Update Date:2019-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO116671835P0018X
FLPS213641835P0018X
IL051.0368831835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist