Provider Demographics
NPI:1639797954
Name:OTTERSTATTER, MICHAELA ROSE
Entity Type:Individual
Prefix:
First Name:MICHAELA
Middle Name:ROSE
Last Name:OTTERSTATTER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 LAKE SHORE DR W
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:WI
Mailing Address - Zip Code:54806-1645
Mailing Address - Country:US
Mailing Address - Phone:715-685-0202
Mailing Address - Fax:715-685-0208
Practice Address - Street 1:110 LAKE SHORE DR W
Practice Address - Street 2:
Practice Address - City:ASHLAND
Practice Address - State:WI
Practice Address - Zip Code:54806-1645
Practice Address - Country:US
Practice Address - Phone:715-685-0202
Practice Address - Fax:715-685-0208
Is Sole Proprietor?:No
Enumeration Date:2020-07-13
Last Update Date:2020-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI20376-40183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist