Provider Demographics
NPI:1891549911
Name:OTAMIRI, QUEENETTE CHIMEUCHEYA
Entity Type:Individual
Prefix:
First Name:QUEENETTE
Middle Name:CHIMEUCHEYA
Last Name:OTAMIRI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1620 S BROADWAY AVE
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75701-4260
Mailing Address - Country:US
Mailing Address - Phone:903-533-0367
Mailing Address - Fax:903-533-1063
Practice Address - Street 1:1620 S BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-4260
Practice Address - Country:US
Practice Address - Phone:903-533-0367
Practice Address - Fax:903-533-1063
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-15
Last Update Date:2024-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX73872183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist