Provider Demographics
NPI:1639385404
Name:BOTHA, CLARK ANTHONY (BPHARM, RPH)
Entity Type:Individual
Prefix:MR
First Name:CLARK
Middle Name:ANTHONY
Last Name:BOTHA
Suffix:
Gender:M
Credentials:BPHARM, RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25590 PROSPECT AVE
Mailing Address - Street 2:APT 26D
Mailing Address - City:LOMA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92354-3141
Mailing Address - Country:US
Mailing Address - Phone:909-801-4312
Mailing Address - Fax:
Practice Address - Street 1:81 HIGHLAND SPRINGS AVE STE 90
Practice Address - Street 2:
Practice Address - City:BEAUMONT
Practice Address - State:CA
Practice Address - Zip Code:92223-3170
Practice Address - Country:US
Practice Address - Phone:951-849-3378
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-16
Last Update Date:2019-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA58078183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist