Provider Demographics
NPI:1659812048
Name:HANNA, BOTROS (PHARMACIST)
Entity Type:Individual
Prefix:
First Name:BOTROS
Middle Name:
Last Name:HANNA
Suffix:
Gender:M
Credentials:PHARMACIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2420 DAWS DR
Mailing Address - Street 2:APT D
Mailing Address - City:BOZEMAN
Mailing Address - State:MT
Mailing Address - Zip Code:59718-6979
Mailing Address - Country:US
Mailing Address - Phone:508-250-9763
Mailing Address - Fax:
Practice Address - Street 1:2420 DAWS DR
Practice Address - Street 2:APT D
Practice Address - City:BOZEMAN
Practice Address - State:MT
Practice Address - Zip Code:59718-6979
Practice Address - Country:US
Practice Address - Phone:508-250-9763
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-17
Last Update Date:2017-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT42802183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLH500-069-77-201-0OtherFLORIDA DRIVER LICENSE