Provider Demographics
NPI:1861787434
Name:OTTO, TERRANCE LEE
Entity type:Individual
Prefix:MR
First Name:TERRANCE
Middle Name:LEE
Last Name:OTTO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5577 GIRDLE RD
Mailing Address - Street 2:
Mailing Address - City:WEST FARMINGTON
Mailing Address - State:OH
Mailing Address - Zip Code:44491-9724
Mailing Address - Country:US
Mailing Address - Phone:440-318-5154
Mailing Address - Fax:
Practice Address - Street 1:2250 HICKORY RD
Practice Address - Street 2:SUITE 240
Practice Address - City:PLYMOUTH MEETING
Practice Address - State:PA
Practice Address - Zip Code:19462-1047
Practice Address - Country:US
Practice Address - Phone:800-879-4471
Practice Address - Fax:888-701-2089
Is Sole Proprietor?:No
Enumeration Date:2011-06-12
Last Update Date:2011-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH270100103110052183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH270100103110052OtherPTCB CERTIFICATION -CERTIFIED PHARMACY TECHNICIAN