Provider Demographics
NPI:1063905578
Name:OTA, JENNIFER (PHARMD)
Entity type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:
Last Name:OTA
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3009 ALA MAKAHALA PL APT 1116
Mailing Address - Street 2:
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96818-7607
Mailing Address - Country:US
Mailing Address - Phone:808-497-3567
Mailing Address - Fax:
Practice Address - Street 1:3288 MOANALUA RD
Practice Address - Street 2:
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96819-1469
Practice Address - Country:US
Practice Address - Phone:808-497-3568
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-08
Last Update Date:2018-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIPH-3700183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist