Provider Demographics
NPI:1154604403
Name:KOTHA, BHANU PRAKASH
Entity type:Individual
Prefix:
First Name:BHANU
Middle Name:PRAKASH
Last Name:KOTHA
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:S/O K.V.RATTAIAH(RTD HM)
Mailing Address - Street 2:EMPLOYEES COLONY
Mailing Address - City:MARTURU
Mailing Address - State:ANDHRA PRADESH
Mailing Address - Zip Code:523301
Mailing Address - Country:IN
Mailing Address - Phone:00191840-427-2111
Mailing Address - Fax:
Practice Address - Street 1:12463 SW 124TH PATH
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33186-5410
Practice Address - Country:US
Practice Address - Phone:305-964-7311
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-22
Last Update Date:2011-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS 39623183500000X
NJ28RI03411300183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist