Provider Demographics
NPI:1518713056
Name:BOTROUS, FADY
Entity Type:Individual
Prefix:
First Name:FADY
Middle Name:
Last Name:BOTROUS
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 1:173 E CLAY AVE
Mailing Address - Street 2:
Mailing Address - City:ROSELLE PARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07204-2033
Mailing Address - Country:US
Mailing Address - Phone:732-376-1600
Mailing Address - Fax:732-376-1602
Practice Address - Street 1:501 NEW BRUNSWICK AVE
Practice Address - Street 2:
Practice Address - City:PERTH AMBOY
Practice Address - State:NJ
Practice Address - Zip Code:08861-3653
Practice Address - Country:US
Practice Address - Phone:732-376-1600
Practice Address - Fax:732-376-1602
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-25
Last Update Date:2024-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RW03442300183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician