MEDICARE: DANIEL RYAN OTIS PHARM.D

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1835P0018X	Pharmacist Clinician (PhC)/ Clinical Pharmacy Specialist	S026502	AZ

General Provider Information

NPI Number	:	1851071450
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DANIEL RYAN OTIS PHARM.D

Provider Business Mailing Address
First Line	:	5901 W BEHREND DR APT 1091
Second Line	:
City	:	GLENDALE
State	:	AZ
Zip	:	85308-6939
Country	:	US
Telephone Number	:	208-403-2162
Fax Number	:

Provider Business Practice Location Address
First Line	:	6601 W INDIAN SCHOOL RD
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85033-3339
Country	:	US
Telephone Number	:	623-846-1533
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/19/2023
Last Update Date	:	07/19/2023

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