Provider Demographics
NPI:1952873341
Name:OTIENO, GRACE AWINO (PHARMD)
Entity Type:Individual
Prefix:MS
First Name:GRACE
Middle Name:AWINO
Last Name:OTIENO
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3112 CRANE ST
Mailing Address - Street 2:
Mailing Address - City:SHAKOPEE
Mailing Address - State:MN
Mailing Address - Zip Code:55379-4499
Mailing Address - Country:US
Mailing Address - Phone:505-922-5522
Mailing Address - Fax:
Practice Address - Street 1:3112 CRANE ST
Practice Address - Street 2:
Practice Address - City:SHAKOPEE
Practice Address - State:MN
Practice Address - Zip Code:55379-4499
Practice Address - Country:US
Practice Address - Phone:505-922-5522
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-22
Last Update Date:2018-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN123610183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist