Provider Demographics
NPI:1124718051
Name:KOTLARZ, BROOK ALLISON (PHARMD)
Entity type:Individual
Prefix:DR
First Name:BROOK
Middle Name:ALLISON
Last Name:KOTLARZ
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:103 E COLLEGE AVE
Mailing Address - Street 2:
Mailing Address - City:ST MARIES
Mailing Address - State:ID
Mailing Address - Zip Code:83861-2247
Mailing Address - Country:US
Mailing Address - Phone:208-245-4578
Mailing Address - Fax:
Practice Address - Street 1:103 E COLLEGE AVE
Practice Address - Street 2:
Practice Address - City:ST MARIES
Practice Address - State:ID
Practice Address - Zip Code:83861-2247
Practice Address - Country:US
Practice Address - Phone:208-245-4578
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-12
Last Update Date:2023-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAIR60974831183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist