Provider Demographics
NPI:1629326053
Name:BOTILL, LESTER H
Entity Type:Individual
Prefix:MR
First Name:LESTER
Middle Name:H
Last Name:BOTILL
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 1:2730 SHAFFER ROAD
Mailing Address - Street 2:
Mailing Address - City:ATWATER
Mailing Address - State:CA
Mailing Address - Zip Code:95301
Mailing Address - Country:US
Mailing Address - Phone:209-357-9430
Mailing Address - Fax:209-357-9595
Practice Address - Street 1:2730 SHAFFER RD
Practice Address - Street 2:
Practice Address - City:ATWATER
Practice Address - State:CA
Practice Address - Zip Code:95301-2225
Practice Address - Country:US
Practice Address - Phone:209-357-9430
Practice Address - Fax:209-357-9595
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-15
Last Update Date:2012-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA28416183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist