Provider Demographics
NPI:1013320126
Name:BOUTROS, SHERIF
Entity type:Individual
Prefix:
First Name:SHERIF
Middle Name:
Last Name:BOUTROS
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 1:9482 CALIFORNIA CITY BLVD
Mailing Address - Street 2:
Mailing Address - City:CALIFORNIA CITY
Mailing Address - State:CA
Mailing Address - Zip Code:93505-2803
Mailing Address - Country:US
Mailing Address - Phone:760-373-5268
Mailing Address - Fax:
Practice Address - Street 1:9482 CALIFORNIA CITY BLVD
Practice Address - Street 2:
Practice Address - City:CALIFORNIA CITY
Practice Address - State:CA
Practice Address - Zip Code:93505-2803
Practice Address - Country:US
Practice Address - Phone:760-373-5268
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-05
Last Update Date:2014-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA65237183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist