Provider Demographics
NPI:1093395840
Name:BOTROS, HANY
Entity Type:Individual
Prefix:
First Name:HANY
Middle Name:
Last Name:BOTROS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7780 N WICKHAM RD
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32940-8262
Mailing Address - Country:US
Mailing Address - Phone:321-254-1072
Mailing Address - Fax:321-254-0656
Practice Address - Street 1:7780 N WICKHAM RD
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32940-8262
Practice Address - Country:US
Practice Address - Phone:321-254-1072
Practice Address - Fax:321-254-0656
Is Sole Proprietor?:No
Enumeration Date:2021-04-14
Last Update Date:2021-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS61437183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPS61437OtherWALGREENS
FLPS61437OtherLICENSE CERTIFICATE