Provider Demographics
NPI:1265900294
Name:OTANI, CARRIE
Entity type:Individual
Prefix:
First Name:CARRIE
Middle Name:
Last Name:OTANI
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 1:4561 S CENTINELA AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90066-6248
Mailing Address - Country:US
Mailing Address - Phone:310-822-6354
Mailing Address - Fax:310-822-6540
Practice Address - Street 1:4561 S CENTINELA AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90066-6248
Practice Address - Country:US
Practice Address - Phone:310-822-6354
Practice Address - Fax:310-822-6540
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-07
Last Update Date:2018-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPHY569353336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy