Provider Demographics
NPI:1689808537
Name:BOTHMA, GEORGE FREDERICK
Entity Type:Individual
Prefix:MR
First Name:GEORGE
Middle Name:FREDERICK
Last Name:BOTHMA
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 1:11073 STREAMSIDE DR NE
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:MI
Mailing Address - Zip Code:49341-8604
Mailing Address - Country:US
Mailing Address - Phone:616-866-2450
Mailing Address - Fax:
Practice Address - Street 1:100 COVERED VLG
Practice Address - Street 2:
Practice Address - City:BELDING
Practice Address - State:MI
Practice Address - Zip Code:48809-1683
Practice Address - Country:US
Practice Address - Phone:616-794-2200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-06
Last Update Date:2009-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302036700183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist