Provider Demographics
NPI:1104266469
Name:OTTA, JASON DEAN (RPH)
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:DEAN
Last Name:OTTA
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1201 HYANNIS PORT LN
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57106-5467
Mailing Address - Country:US
Mailing Address - Phone:605-362-6653
Mailing Address - Fax:
Practice Address - Street 1:3201 S LOUISE AVE
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57106-0704
Practice Address - Country:US
Practice Address - Phone:605-362-2625
Practice Address - Fax:605-362-2636
Is Sole Proprietor?:No
Enumeration Date:2013-07-01
Last Update Date:2013-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD4853183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist