Provider Demographics
NPI:1083033583
Name:OTERO, SALLY FEASTER (RPH)
Entity Type:Individual
Prefix:
First Name:SALLY
Middle Name:FEASTER
Last Name:OTERO
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 LONGWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32955-2828
Mailing Address - Country:US
Mailing Address - Phone:321-636-2211
Mailing Address - Fax:
Practice Address - Street 1:110 LONGWOOD AVE
Practice Address - Street 2:
Practice Address - City:ROCKLEDGE
Practice Address - State:FL
Practice Address - Zip Code:32955-2828
Practice Address - Country:US
Practice Address - Phone:321-636-2211
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-11
Last Update Date:2014-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS19115183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist