Provider Demographics
NPI:1508342056
Name:KOTTWITZ, MELVIN EUGENE (RPH)
Entity Type:Individual
Prefix:MR
First Name:MELVIN
Middle Name:EUGENE
Last Name:KOTTWITZ
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 1:101 CIVIC CENTER DR
Mailing Address - Street 2:
Mailing Address - City:LAKE ST LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63367-3027
Mailing Address - Country:US
Mailing Address - Phone:636-561-3963
Mailing Address - Fax:636-561-5317
Practice Address - Street 1:101 CIVIC CENTER DR
Practice Address - Street 2:
Practice Address - City:LAKE ST LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63367-3027
Practice Address - Country:US
Practice Address - Phone:636-561-3963
Practice Address - Fax:636-561-5317
Is Sole Proprietor?:No
Enumeration Date:2018-07-18
Last Update Date:2018-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO40445183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist