Provider Demographics
NPI:1437678059
Name:KOTULA, JACLYN (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:JACLYN
Middle Name:
Last Name:KOTULA
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 1:2213 E 18TH ST
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87401-7530
Mailing Address - Country:US
Mailing Address - Phone:585-815-9277
Mailing Address - Fax:
Practice Address - Street 1:HWY 491 N
Practice Address - Street 2:
Practice Address - City:SHIPROCK
Practice Address - State:NM
Practice Address - Zip Code:87420
Practice Address - Country:US
Practice Address - Phone:505-368-7266
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-14
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0604541835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist