Provider Demographics
NPI:1902134083
Name:KOTANATIONAL MERCANTILE INC
Entity Type:Organization
Organization Name:KOTANATIONAL MERCANTILE INC
Other - Org Name:CINDERELLON
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:TONY
Authorized Official - Middle Name:F
Authorized Official - Last Name:ORUKOTAN
Authorized Official - Suffix:
Authorized Official - Credentials:PHARM D
Authorized Official - Phone:305-751-2783
Mailing Address - Street 1:128 NE 54TH ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33137-2416
Mailing Address - Country:US
Mailing Address - Phone:305-751-2783
Mailing Address - Fax:305-758-3522
Practice Address - Street 1:128 NE 54TH ST
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33137-2416
Practice Address - Country:US
Practice Address - Phone:305-751-2783
Practice Address - Fax:305-758-3522
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-11-30
Last Update Date:2009-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPH112153336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL100748300Medicaid