Provider Demographics
NPI:1619577970
Name:BOTTI, KYLE
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:
Last Name:BOTTI
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 1:3611 DARTMOUTH AVE N
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33713-7543
Mailing Address - Country:US
Mailing Address - Phone:954-643-9861
Mailing Address - Fax:
Practice Address - Street 1:2575 GULF TO BAY BLVD
Practice Address - Street 2:
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33765-4433
Practice Address - Country:US
Practice Address - Phone:727-712-1363
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-27
Last Update Date:2020-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS52678183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist