Provider Demographics
NPI:1144644840
Name:OTTERSON, SEAN (PS 40415)
Entity type:Individual
Prefix:
First Name:SEAN
Middle Name:
Last Name:OTTERSON
Suffix:
Gender:M
Credentials:PS 40415
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:332 PONTE VEDRA RD
Mailing Address - Street 2:
Mailing Address - City:PALM SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:33461-1821
Mailing Address - Country:US
Mailing Address - Phone:561-818-3559
Mailing Address - Fax:
Practice Address - Street 1:5499 N FEDERAL HWY
Practice Address - Street 2:
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33487-4993
Practice Address - Country:US
Practice Address - Phone:561-826-0711
Practice Address - Fax:561-826-0717
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-15
Last Update Date:2014-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS 40415183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPS40415OtherREGISTERED PHARMACIST