Healthcare Provider Details

I. General information

NPI: 1124963772
Provider Name (Legal Business Name): KELLY MARIE OETTINGER PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/21/2026
Last Update Date: 04/21/2026
Certification Date: 04/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8400 WASHINGTON AVE
MOUNT PLEASANT WI
53406-3735
US

IV. Provider business mailing address

2858 TRUDEAU TRCE
MOUNT PLEASANT WI
53406-1534
US

V. Phone/Fax

Practice location:
  • Phone: 262-884-3853
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number13490-40
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: