Provider Demographics
NPI:1376808576
Name:BOTROS, ASHAK FAKOUS (PHARMD)
Entity Type:Individual
Prefix:MR
First Name:ASHAK
Middle Name:FAKOUS
Last Name:BOTROS
Suffix:
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 1:9245 REGENTS RD UNIT M107
Mailing Address - Street 2:
Mailing Address - City:LA JOLLA
Mailing Address - State:CA
Mailing Address - Zip Code:92037-9264
Mailing Address - Country:US
Mailing Address - Phone:818-919-9723
Mailing Address - Fax:858-412-4306
Practice Address - Street 1:1021 BRIDGE ST
Practice Address - Street 2:
Practice Address - City:COLUSA
Practice Address - State:CA
Practice Address - Zip Code:95932-2839
Practice Address - Country:US
Practice Address - Phone:530-458-2494
Practice Address - Fax:858-412-4306
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-12
Last Update Date:2012-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA67020183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist