Provider Demographics
NPI:1134523616
Name:OTOUM, SUFIAN (PHARM D)
Entity type:Individual
Prefix:DR
First Name:SUFIAN
Middle Name:
Last Name:OTOUM
Suffix:
Gender:M
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6185 MAGNOLIA AVE
Mailing Address - Street 2:# 132
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92506-2524
Mailing Address - Country:US
Mailing Address - Phone:909-210-7206
Mailing Address - Fax:
Practice Address - Street 1:3131 CAMINO DEL RIO N
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92108-5701
Practice Address - Country:US
Practice Address - Phone:800-788-4863
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-10-13
Last Update Date:2014-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA53174183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist