Provider Demographics
NPI:1093084790
Name:BOTTORFF, STEPHEN EUGENE (RPH)
Entity Type:Individual
Prefix:MR
First Name:STEPHEN
Middle Name:EUGENE
Last Name:BOTTORFF
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 1:12199 HESPERIA RD
Mailing Address - Street 2:
Mailing Address - City:VICTORVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:92395-4756
Mailing Address - Country:US
Mailing Address - Phone:760-241-8384
Mailing Address - Fax:760-843-0378
Practice Address - Street 1:12199 HESPERIA RD
Practice Address - Street 2:
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92395-4756
Practice Address - Country:US
Practice Address - Phone:760-241-8384
Practice Address - Fax:760-843-0378
Is Sole Proprietor?:No
Enumeration Date:2011-12-26
Last Update Date:2011-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA28510183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1356387963Medicare PIN