Provider Demographics
NPI:1588097323
Name:CLEVELAND, OTIS JR (PHARMD)
Entity type:Individual
Prefix:DR
First Name:OTIS
Middle Name:
Last Name:CLEVELAND
Suffix:JR
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 1:10 KING STREET
Mailing Address - Street 2:
Mailing Address - City:WALDORF
Mailing Address - State:MD
Mailing Address - Zip Code:20602
Mailing Address - Country:US
Mailing Address - Phone:301-645-5161
Mailing Address - Fax:301-374-9873
Practice Address - Street 1:10 KING STREET
Practice Address - Street 2:
Practice Address - City:WALDORF
Practice Address - State:MD
Practice Address - Zip Code:20602
Practice Address - Country:US
Practice Address - Phone:301-645-5161
Practice Address - Fax:301-374-9783
Is Sole Proprietor?:No
Enumeration Date:2013-08-15
Last Update Date:2014-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD17636183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist