Provider Demographics
NPI:1902317613
Name:OTERO DE SANTIAGO, RAFAEL (PHARMD)
Entity Type:Individual
Prefix:
First Name:RAFAEL
Middle Name:
Last Name:OTERO DE SANTIAGO
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:349 HOMELAND SOUTHWAY 1B
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21212
Mailing Address - Country:US
Mailing Address - Phone:787-367-2446
Mailing Address - Fax:
Practice Address - Street 1:4625 FALLS RD
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21209-5025
Practice Address - Country:US
Practice Address - Phone:410-662-1670
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-20
Last Update Date:2017-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD25369183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist