Provider Demographics
NPI:1821438276
Name:OTTO, JEREMY D (PHARMD)
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:D
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 1:250 MEIJER DR
Mailing Address - Street 2:
Mailing Address - City:GAYLORD
Mailing Address - State:MI
Mailing Address - Zip Code:49735-7241
Mailing Address - Country:US
Mailing Address - Phone:989-731-9010
Mailing Address - Fax:989-731-9065
Practice Address - Street 1:250 MEIJER DR
Practice Address - Street 2:
Practice Address - City:GAYLORD
Practice Address - State:MI
Practice Address - Zip Code:49735-7241
Practice Address - Country:US
Practice Address - Phone:989-731-9010
Practice Address - Fax:989-731-9065
Is Sole Proprietor?:No
Enumeration Date:2013-06-30
Last Update Date:2018-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302038643183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist