Provider Demographics
NPI:1982991527
Name:OTTO, JEFFREY RICHARD (RPH)
Entity Type:Individual
Prefix:MR
First Name:JEFFREY
Middle Name:RICHARD
Last Name:OTTO
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:N95W17707 SHADY LN
Mailing Address - Street 2:
Mailing Address - City:MENOMONEE FALLS
Mailing Address - State:WI
Mailing Address - Zip Code:53051-8012
Mailing Address - Country:US
Mailing Address - Phone:262-415-0005
Mailing Address - Fax:262-415-0005
Practice Address - Street 1:N95W17707 SHADY LN
Practice Address - Street 2:
Practice Address - City:MENOMONEE FALLS
Practice Address - State:WI
Practice Address - Zip Code:53051-8012
Practice Address - Country:US
Practice Address - Phone:262-415-0005
Practice Address - Fax:262-415-0005
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-04
Last Update Date:2011-07-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI12967-040183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist