Provider Demographics
NPI:1366194318
Name:OTTO, ZACHARY T (PHARMD)
Entity type:Individual
Prefix:
First Name:ZACHARY
Middle Name:T
Last Name:OTTO
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4001 E SUPERIOR ST
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55804-2173
Mailing Address - Country:US
Mailing Address - Phone:715-938-0862
Mailing Address - Fax:
Practice Address - Street 1:3500 TOWER AVE STE A
Practice Address - Street 2:
Practice Address - City:SUPERIOR
Practice Address - State:WI
Practice Address - Zip Code:54880-4685
Practice Address - Country:US
Practice Address - Phone:715-817-7880
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-21
Last Update Date:2022-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI20598-401835P2201X
MN1250091835P2201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P2201XPharmacy Service ProvidersPharmacistAmbulatory Care