Provider Demographics
NPI:1376207878
Name:GOTLIB, ALITA JADE (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:ALITA
Middle Name:JADE
Last Name:GOTLIB
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:391 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:NY
Mailing Address - Zip Code:11743-3296
Mailing Address - Country:US
Mailing Address - Phone:631-549-9400
Mailing Address - Fax:631-549-1190
Practice Address - Street 1:391 W MAIN ST
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:NY
Practice Address - Zip Code:11743-3296
Practice Address - Country:US
Practice Address - Phone:631-549-9400
Practice Address - Fax:631-549-1190
Is Sole Proprietor?:No
Enumeration Date:2021-10-30
Last Update Date:2021-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY068619183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist