Provider Demographics
NPI:1568188993
Name:OTALUKA, BRYAN I
Entity Type:Individual
Prefix:
First Name:BRYAN
Middle Name:I
Last Name:OTALUKA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4416 HOLLOW STUMP RUN
Mailing Address - Street 2:
Mailing Address - City:PALMETTO
Mailing Address - State:FL
Mailing Address - Zip Code:34221-1290
Mailing Address - Country:US
Mailing Address - Phone:770-878-1627
Mailing Address - Fax:
Practice Address - Street 1:4240 53RD AVE E
Practice Address - Street 2:
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34203-8097
Practice Address - Country:US
Practice Address - Phone:941-758-4093
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-18
Last Update Date:2022-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS65013183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist