=====================================================
General NPI Number Information
=====================================================
NPI Number | 1265900294
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CARRIE OTANI
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/07/2018
-----------------------------------------------------
Last Update Date | 11/07/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4561 S CENTINELA AVE
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90066-6248
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-822-6354
-----------------------------------------------------
Fax | 310-822-6540
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4561 S CENTINELA AVE
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90066-6248
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-822-6354
-----------------------------------------------------
Fax | 310-822-6540
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | PHY56935
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------