Provider Demographics
NPI:1790316354
Name:KOTANI, DYANA
Entity Type:Individual
Prefix:
First Name:DYANA
Middle Name:
Last Name:KOTANI
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 1:37792 BLOSSOM LN
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48331-1734
Mailing Address - Country:US
Mailing Address - Phone:248-535-4482
Mailing Address - Fax:
Practice Address - Street 1:4995 HIGHLAND RD
Practice Address - Street 2:
Practice Address - City:WATERFORD
Practice Address - State:MI
Practice Address - Zip Code:48328-1143
Practice Address - Country:US
Practice Address - Phone:248-674-2261
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-31
Last Update Date:2020-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302411950183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist