Provider Demographics
NPI:1376882167
Name:BOTOR, OLIVE EDWINA (PHARMD)
Entity Type:Individual
Prefix:
First Name:OLIVE
Middle Name:EDWINA
Last Name:BOTOR
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1302 N VIRGINIA ST
Mailing Address - Street 2:
Mailing Address - City:PORT LAVACA
Mailing Address - State:TX
Mailing Address - Zip Code:77979-2509
Mailing Address - Country:US
Mailing Address - Phone:361-552-7451
Mailing Address - Fax:361-552-7594
Practice Address - Street 1:1302 N VIRGINIA ST
Practice Address - Street 2:
Practice Address - City:PORT LAVACA
Practice Address - State:TX
Practice Address - Zip Code:77979-2509
Practice Address - Country:US
Practice Address - Phone:361-552-7451
Practice Address - Fax:361-552-7594
Is Sole Proprietor?:No
Enumeration Date:2013-02-14
Last Update Date:2013-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX52505183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist