Provider Demographics
NPI:1821161373
Name:OTA, DOUGLAS MICHAEL (RPH)
Entity Type:Individual
Prefix:MR
First Name:DOUGLAS
Middle Name:MICHAEL
Last Name:OTA
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1460 MARIA LN
Mailing Address - Street 2:250
Mailing Address - City:WALNUT CREEK
Mailing Address - State:CA
Mailing Address - Zip Code:94596-8802
Mailing Address - Country:US
Mailing Address - Phone:925-295-7314
Mailing Address - Fax:925-295-5996
Practice Address - Street 1:1460 MARIA LN
Practice Address - Street 2:250
Practice Address - City:WALNUT CREEK
Practice Address - State:CA
Practice Address - Zip Code:94596-8802
Practice Address - Country:US
Practice Address - Phone:925-295-7314
Practice Address - Fax:925-295-5996
Is Sole Proprietor?:No
Enumeration Date:2006-11-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA36339183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist