Provider Demographics
NPI:1285155465
Name:KOTWICA, JEFFERY SCOTT
Entity type:Individual
Prefix:
First Name:JEFFERY
Middle Name:SCOTT
Last Name:KOTWICA
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 1:1415 E SUNRISE BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33304-2324
Mailing Address - Country:US
Mailing Address - Phone:954-888-8980
Mailing Address - Fax:954-888-8988
Practice Address - Street 1:1415 E SUNRISE BLVD
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33304-2324
Practice Address - Country:US
Practice Address - Phone:954-898-8980
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-28
Last Update Date:2017-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS53183183500000X
FLP53183183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
No183500000XPharmacy Service ProvidersPharmacist