=====================================================
General NPI Number Information
=====================================================
NPI Number | 1710581087
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ELIZABETH DANIELA ORTEGA PHARMD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/26/2020
-----------------------------------------------------
Last Update Date | 11/26/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 214 LAFAYETTE ST
-----------------------------------------------------
City | LONDON
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43140-9059
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 740-852-5644
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8599 OLENCREST DR
-----------------------------------------------------
City | LEWIS CENTER
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43035-8872
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 708-612-5656
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 051298167
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 03438873
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------