Provider Demographics
NPI:1811165673
Name:TROTTA, MICHAEL
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:
Last Name:TROTTA
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 1:1511 ROUTE 22
Mailing Address - Street 2:
Mailing Address - City:BREWSTER
Mailing Address - State:NY
Mailing Address - Zip Code:10509-4020
Mailing Address - Country:US
Mailing Address - Phone:845-940-0565
Mailing Address - Fax:845-940-0565
Practice Address - Street 1:1515 ROUTE 22
Practice Address - Street 2:
Practice Address - City:BREWSTER
Practice Address - State:NY
Practice Address - Zip Code:10509-4042
Practice Address - Country:US
Practice Address - Phone:845-278-5284
Practice Address - Fax:845-278-5287
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-14
Last Update Date:2015-12-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY032040183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY678255OtherNABP E-PROFILE
NY01313895Medicaid