Provider Demographics
NPI:1689066102
Name:OTTO, JOHN
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:OTTO
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 1:210 STERLING RUN BLVD
Mailing Address - Street 2:
Mailing Address - City:MOUNT ORAB
Mailing Address - State:OH
Mailing Address - Zip Code:45154-8350
Mailing Address - Country:US
Mailing Address - Phone:937-444-6911
Mailing Address - Fax:
Practice Address - Street 1:210 STERLING RUN BLVD
Practice Address - Street 2:
Practice Address - City:MOUNT ORAB
Practice Address - State:OH
Practice Address - Zip Code:45154-8350
Practice Address - Country:US
Practice Address - Phone:937-444-6911
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-20
Last Update Date:2015-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03122774183500000X
KY011303183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist