Healthcare Provider Details

I. General information

NPI: 1134492812
Provider Name (Legal Business Name): MARY A. OTIS RPH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/11/2012
Last Update Date: 02/11/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

280 KINGSBURY CT
HIGHLAND IL
62249-2921
US

IV. Provider business mailing address

280 KINGSBURY CT
HIGHLAND IL
62249-2921
US

V. Phone/Fax

Practice location:
  • Phone: 618-654-5469
  • Fax:
Mailing address:
  • Phone: 618-654-5469
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number51-028503
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number027995
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: