Provider Demographics
NPI:1407850399
Name:OTTO, PAUL W (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:PAUL
Middle Name:W
Last Name:OTTO
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4582 W PORTNEUF RD
Mailing Address - Street 2:
Mailing Address - City:INKOM
Mailing Address - State:ID
Mailing Address - Zip Code:83245-1626
Mailing Address - Country:US
Mailing Address - Phone:208-775-3262
Mailing Address - Fax:
Practice Address - Street 1:444 HOSPITAL WAY
Practice Address - Street 2:STE 801
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-2792
Practice Address - Country:US
Practice Address - Phone:208-232-6214
Practice Address - Fax:208-233-3416
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-06-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP5603183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist