Provider Demographics
NPI:1437793221
Name:BOTOLFSON, NEAL
Entity Type:Individual
Prefix:
First Name:NEAL
Middle Name:
Last Name:BOTOLFSON
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 1:3220 SEAWAY DR
Mailing Address - Street 2:
Mailing Address - City:NEW PORT RICHEY
Mailing Address - State:FL
Mailing Address - Zip Code:34652-3028
Mailing Address - Country:US
Mailing Address - Phone:727-846-1428
Mailing Address - Fax:727-264-5223
Practice Address - Street 1:8745 LITTLE RD
Practice Address - Street 2:
Practice Address - City:NEW PORT RICHEY
Practice Address - State:FL
Practice Address - Zip Code:34654-4947
Practice Address - Country:US
Practice Address - Phone:727-264-5224
Practice Address - Fax:727-264-5223
Is Sole Proprietor?:No
Enumeration Date:2019-11-05
Last Update Date:2019-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS23255183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist