1396099305 NPI number — KAYLA OTTERSON PHARMD

Table of content: KAYLA OTTERSON PHARMD (NPI 1396099305)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396099305 NPI number — KAYLA OTTERSON PHARMD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
OTTERSON
Provider First Name:
KAYLA
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PHARMD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1396099305
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/16/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1099 ANDERSON LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SPRINGFIELD
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97477-7682
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
701-367-8542
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1675 COBURG RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EUGENE
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97401-4854
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-334-0015
Provider Business Practice Location Address Fax Number:
541-344-4946
Provider Enumeration Date:
10/30/2012

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 183500000X , with the licence number:  RPH-0013362 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 1835P0018X , with the licence number: ORRPH0013362 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)





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