Provider Demographics
NPI:1831485622
Name:ORTMAN, ALISA BOYETTE (RPH)
Entity Type:Individual
Prefix:MRS
First Name:ALISA
Middle Name:BOYETTE
Last Name:ORTMAN
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:609 VALLEY BROOK LN
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27104-2732
Mailing Address - Country:US
Mailing Address - Phone:336-765-0831
Mailing Address - Fax:
Practice Address - Street 1:2221 CLOVERDALE AVE
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-2301
Practice Address - Country:US
Practice Address - Phone:336-724-7491
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-21
Last Update Date:2011-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC7525183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist