Provider Demographics
NPI:1821098278
Name:COTA, MARK MICHAEL
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:MICHAEL
Last Name:COTA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2346 PINEVIEW CT
Mailing Address - Street 2:
Mailing Address - City:RED WING
Mailing Address - State:MN
Mailing Address - Zip Code:55066-4041
Mailing Address - Country:US
Mailing Address - Phone:651-388-5714
Mailing Address - Fax:
Practice Address - Street 1:401 W 3RD ST
Practice Address - Street 2:
Practice Address - City:RED WING
Practice Address - State:MN
Practice Address - Zip Code:55066-2310
Practice Address - Country:US
Practice Address - Phone:651-388-3521
Practice Address - Fax:651-388-8059
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN115215-1183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist