Provider Demographics
NPI:1841586195
Name:BOETTNER, SUSAN KOLTAS (RPH)
Entity Type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:KOLTAS
Last Name:BOETTNER
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 1:3720 SOLDANO BLVD
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43228-1422
Mailing Address - Country:US
Mailing Address - Phone:614-279-5678
Mailing Address - Fax:614-279-5678
Practice Address - Street 1:3720 SOLDANO BLVD
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43228-1422
Practice Address - Country:US
Practice Address - Phone:614-279-5678
Practice Address - Fax:614-279-5678
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-24
Last Update Date:2011-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03-3-18390183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist