Provider Demographics
NPI:1982864831
Name:PETER BOTROS PHARMACY INC
Entity Type:Organization
Organization Name:PETER BOTROS PHARMACY INC
Other - Org Name:PETER'S PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT & OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:SHALBY
Authorized Official - Last Name:KAMEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:386-734-8477
Mailing Address - Street 1:121 VICTORIA COMMONS BLVD
Mailing Address - Street 2:SUITE #102
Mailing Address - City:DELAND
Mailing Address - State:FL
Mailing Address - Zip Code:32724
Mailing Address - Country:US
Mailing Address - Phone:386-734-8477
Mailing Address - Fax:386-734-8488
Practice Address - Street 1:121 VICTORIA COMMONS BLVD
Practice Address - Street 2:SUITE #102
Practice Address - City:DELAND
Practice Address - State:FL
Practice Address - Zip Code:32724
Practice Address - Country:US
Practice Address - Phone:386-734-8477
Practice Address - Fax:386-734-8488
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-13
Last Update Date:2019-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336L0003X
FLPH233963336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2128204OtherPK
FL000362700Medicaid
1035496OtherNCPDP PROVIDER IDENTIFICATION NUMBER