Provider Demographics
NPI:1568677649
Name:KOTREDES, DEBRA BRYANT (RPH)
Entity Type:Individual
Prefix:MRS
First Name:DEBRA
Middle Name:BRYANT
Last Name:KOTREDES
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:48 KNOX AVE
Mailing Address - Street 2:
Mailing Address - City:BANGOR
Mailing Address - State:ME
Mailing Address - Zip Code:04401-3316
Mailing Address - Country:US
Mailing Address - Phone:207-947-8369
Mailing Address - Fax:207-947-0894
Practice Address - Street 1:210 STATE ST
Practice Address - Street 2:
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401-5411
Practice Address - Country:US
Practice Address - Phone:207-947-8369
Practice Address - Fax:207-947-0894
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPR3577183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist