Provider Demographics
NPI:1851777908
Name:HANNA, ANDRE FOUAD BOTROS
Entity Type:Individual
Prefix:
First Name:ANDRE
Middle Name:FOUAD BOTROS
Last Name:HANNA
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 1:196 GREENMOOR
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92614-7514
Mailing Address - Country:US
Mailing Address - Phone:714-723-4748
Mailing Address - Fax:
Practice Address - Street 1:196 GREENMOOR
Practice Address - Street 2:
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92614-7514
Practice Address - Country:US
Practice Address - Phone:714-723-4748
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-30
Last Update Date:2015-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA70774183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist