Provider Demographics
NPI:1184004699
Name:BOTROS, MEDHAT
Entity Type:Individual
Prefix:
First Name:MEDHAT
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 1:79719 PARKWAY ESPLANADE S
Mailing Address - Street 2:
Mailing Address - City:LA QUINTA
Mailing Address - State:CA
Mailing Address - Zip Code:92253-4090
Mailing Address - Country:US
Mailing Address - Phone:760-770-3097
Mailing Address - Fax:
Practice Address - Street 1:69155 RAMON RD
Practice Address - Street 2:
Practice Address - City:CATHEDRAL CITY
Practice Address - State:CA
Practice Address - Zip Code:92234-3344
Practice Address - Country:US
Practice Address - Phone:760-770-3097
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-01
Last Update Date:2021-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA74604183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist