Provider Demographics
NPI:1023305257
Name:OTERO, EDWIN
Entity type:Individual
Prefix:
First Name:EDWIN
Middle Name:
Last Name:OTERO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:550 AVE 167 WALGREENS PLAZA TROPICAL
Mailing Address - Street 2:
Mailing Address - City:BAYAMON
Mailing Address - State:PR
Mailing Address - Zip Code:00959
Mailing Address - Country:US
Mailing Address - Phone:787-395-7480
Mailing Address - Fax:787-395-7482
Practice Address - Street 1:100 AVE BOULEVARD DR
Practice Address - Street 2:
Practice Address - City:BAYAMON
Practice Address - State:PR
Practice Address - Zip Code:00959
Practice Address - Country:US
Practice Address - Phone:787-395-7480
Practice Address - Fax:787-395-7482
Is Sole Proprietor?:No
Enumeration Date:2011-07-08
Last Update Date:2011-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR4224183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist