Provider Demographics
NPI:1043509631
Name:OTT, FRED M (RPH)
Entity Type:Individual
Prefix:
First Name:FRED
Middle Name:M
Last Name:OTT
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 1:10789 W DASON CT
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83713-1850
Mailing Address - Country:US
Mailing Address - Phone:208-375-1486
Mailing Address - Fax:
Practice Address - Street 1:5425 W CHINDEN BLVD
Practice Address - Street 2:
Practice Address - City:GARDEN CITY
Practice Address - State:ID
Practice Address - Zip Code:83714-1468
Practice Address - Country:US
Practice Address - Phone:208-323-7036
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-04
Last Update Date:2011-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP4096183500000X
IDCS2026183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist