Provider Demographics
NPI:1245649623
Name:KOTHARI, RAJIV
Entity type:Individual
Prefix:
First Name:RAJIV
Middle Name:
Last Name:KOTHARI
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 1:1504 FALCON POINTE LN
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95661-4009
Mailing Address - Country:US
Mailing Address - Phone:916-791-7679
Mailing Address - Fax:
Practice Address - Street 1:3095 MCMURRAY DR
Practice Address - Street 2:
Practice Address - City:ANDERSON
Practice Address - State:CA
Practice Address - Zip Code:96007-3674
Practice Address - Country:US
Practice Address - Phone:530-365-5753
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-11
Last Update Date:2014-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA42367183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist