Provider Demographics
NPI:1326451261
Name:KOTARU, SUJATHA
Entity Type:Individual
Prefix:MISS
First Name:SUJATHA
Middle Name:
Last Name:KOTARU
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:165 HAUT BRION AVE
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:DE
Mailing Address - Zip Code:19702-4537
Mailing Address - Country:US
Mailing Address - Phone:302-836-3699
Mailing Address - Fax:
Practice Address - Street 1:1003 PULASKI HWY
Practice Address - Street 2:
Practice Address - City:HAVRE DE GRACE
Practice Address - State:MD
Practice Address - Zip Code:21078-2603
Practice Address - Country:US
Practice Address - Phone:410-939-1140
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-09
Last Update Date:2014-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD17824183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist