Provider Demographics
NPI:1316122385
Name:KOUTOVAS, NICHOLAS F (RPH)
Entity type:Individual
Prefix:MR
First Name:NICHOLAS
Middle Name:F
Last Name:KOUTOVAS
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:113 E KINGSBRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10468-7510
Mailing Address - Country:US
Mailing Address - Phone:718-364-5219
Mailing Address - Fax:718-364-6259
Practice Address - Street 1:1-13 E KINGSBRIDGE RD
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10468
Practice Address - Country:US
Practice Address - Phone:718-364-5219
Practice Address - Fax:718-364-6259
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-08
Last Update Date:2015-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY042178183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01562463Medicaid