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NPI Code Detail

MEDICARE: FRED M OTT RPH

MEDICARE: FRED M OTT RPH
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1183500000XPharmacistP4096ID
2183500000XPharmacistCS2026ID

General Provider Information

NPI Number : 1043509631
Entity Type Code : Individual
Provider Name (Legal Business Name) : FRED M OTT RPH
Provider Business Mailing Address
First Line : 10789 W DASON CT
Second Line :
City : BOISE
State : ID
Zip : 83713-1850
Country : US
Telephone Number : 208-375-1486
Fax Number :
Provider Business Practice Location Address
First Line : 5425 W CHINDEN BLVD
Second Line :
City : GARDEN CITY
State : ID
Zip : 83714-1468
Country : US
Telephone Number : 208-323-7036
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 04/04/2011
Last Update Date : 04/04/2011

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