Provider Demographics
NPI:1134492812
Name:OTIS, MARY A (RPH)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:A
Last Name:OTIS
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 1:280 KINGSBURY CT
Mailing Address - Street 2:
Mailing Address - City:HIGHLAND
Mailing Address - State:IL
Mailing Address - Zip Code:62249-2921
Mailing Address - Country:US
Mailing Address - Phone:618-654-5469
Mailing Address - Fax:
Practice Address - Street 1:280 KINGSBURY CT
Practice Address - Street 2:
Practice Address - City:HIGHLAND
Practice Address - State:IL
Practice Address - Zip Code:62249-2921
Practice Address - Country:US
Practice Address - Phone:618-654-5469
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-11
Last Update Date:2012-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL51-028503183500000X
MO027995183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist