Healthcare Provider Details

I. General information

NPI: 1366194318
Provider Name (Legal Business Name): ZACHARY T OTTO PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/21/2022
Last Update Date: 01/21/2022
Certification Date: 01/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3500 TOWER AVE STE A
SUPERIOR WI
54880-4685
US

IV. Provider business mailing address

4001 E SUPERIOR ST
DULUTH MN
55804-2173
US

V. Phone/Fax

Practice location:
  • Phone: 715-817-7880
  • Fax:
Mailing address:
  • Phone: 715-938-0862
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1835P2201X
TaxonomyAmbulatory Care Pharmacist
License Number20598-40
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code1835P2201X
TaxonomyAmbulatory Care Pharmacist
License Number125009
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: