Provider Demographics
NPI:1154319895
Name:OTTO, KIMBERLEE JO (RPH)
Entity Type:Individual
Prefix:MRS
First Name:KIMBERLEE
Middle Name:JO
Last Name:OTTO
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 1:20697 MCPHERSON AVE
Mailing Address - Street 2:
Mailing Address - City:COUNCIL BLUFFS
Mailing Address - State:IA
Mailing Address - Zip Code:51503-5943
Mailing Address - Country:US
Mailing Address - Phone:402-598-8868
Mailing Address - Fax:
Practice Address - Street 1:20697 MCPHERSON AVE
Practice Address - Street 2:
Practice Address - City:COUNCIL BLUFFS
Practice Address - State:IA
Practice Address - Zip Code:51503-5943
Practice Address - Country:US
Practice Address - Phone:402-598-8868
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE10616183500000X
IA18405183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist