Provider Demographics
NPI:1063457638
Name:BROOKHURST DRUG INC TERRY BOTTORFF PRES
Entity Type:Organization
Organization Name:BROOKHURST DRUG INC TERRY BOTTORFF PRES
Other - Org Name:THE DRUGGIST #3
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:TERRY
Authorized Official - Middle Name:M
Authorized Official - Last Name:BOTTORFF
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:714-963-5512
Mailing Address - Street 1:21421 BROOKHURST ST
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92646-7354
Mailing Address - Country:US
Mailing Address - Phone:714-963-4552
Mailing Address - Fax:714-963-1705
Practice Address - Street 1:21421 BROOKHURST ST
Practice Address - Street 2:
Practice Address - City:HUNTINGTON BEACH
Practice Address - State:CA
Practice Address - Zip Code:92646-7354
Practice Address - Country:US
Practice Address - Phone:714-963-4552
Practice Address - Fax:714-963-1705
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-18
Last Update Date:2018-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPHY34032332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPHA169070Medicaid
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