Provider Demographics
NPI:1386935617
Name:OTA, KEITH K (BS)
Entity type:Individual
Prefix:MR
First Name:KEITH
Middle Name:K
Last Name:OTA
Suffix:
Gender:M
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10570 TWIN CITIES RD
Mailing Address - Street 2:
Mailing Address - City:GALT
Mailing Address - State:CA
Mailing Address - Zip Code:95632-8874
Mailing Address - Country:US
Mailing Address - Phone:209-744-1380
Mailing Address - Fax:209-744-1388
Practice Address - Street 1:10570 TWIN CITIES RD
Practice Address - Street 2:
Practice Address - City:GALT
Practice Address - State:CA
Practice Address - Zip Code:95632-8874
Practice Address - Country:US
Practice Address - Phone:209-744-1380
Practice Address - Fax:209-744-1388
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-20
Last Update Date:2011-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA29178183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist