Provider Demographics
NPI:1528337011
Name:OTTO, SUZAN (RPH)
Entity type:Individual
Prefix:
First Name:SUZAN
Middle Name:
Last Name:OTTO
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1441 CAPITOL DR
Mailing Address - Street 2:
Mailing Address - City:PEWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53072-2579
Mailing Address - Country:US
Mailing Address - Phone:262-695-3088
Mailing Address - Fax:
Practice Address - Street 1:1441 CAPITOL DR
Practice Address - Street 2:
Practice Address - City:PEWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53072-2579
Practice Address - Country:US
Practice Address - Phone:262-695-3088
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-29
Last Update Date:2011-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI12290-040183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist