Provider Demographics
NPI:1639680986
Name:KOTAIT, NEDAL
Entity Type:Individual
Prefix:
First Name:NEDAL
Middle Name:
Last Name:KOTAIT
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 1:504 WINSTED RD
Mailing Address - Street 2:
Mailing Address - City:TORRINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06790-2963
Mailing Address - Country:US
Mailing Address - Phone:860-489-2970
Mailing Address - Fax:
Practice Address - Street 1:504 WINSTED RD
Practice Address - Street 2:
Practice Address - City:TORRINGTON
Practice Address - State:CT
Practice Address - Zip Code:06790-2963
Practice Address - Country:US
Practice Address - Phone:860-489-2970
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-13
Last Update Date:2017-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0008769183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist