Provider Demographics
NPI:1275834939
Name:OTT, JACK LYNN (RPH)
Entity Type:Individual
Prefix:MR
First Name:JACK
Middle Name:LYNN
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 1:600 W FRANKLIN ST
Mailing Address - Street 2:
Mailing Address - City:SHELTON
Mailing Address - State:WA
Mailing Address - Zip Code:98584-3519
Mailing Address - Country:US
Mailing Address - Phone:360-426-0718
Mailing Address - Fax:360-426-2497
Practice Address - Street 1:600 W FRANKLIN ST
Practice Address - Street 2:
Practice Address - City:SHELTON
Practice Address - State:WA
Practice Address - Zip Code:98584-3519
Practice Address - Country:US
Practice Address - Phone:360-426-0718
Practice Address - Fax:360-426-2497
Is Sole Proprietor?:No
Enumeration Date:2010-11-11
Last Update Date:2010-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH00010648183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist