Provider Demographics
NPI:1023065521
Name:BOTTS, JERRY E (PHARM D)
Entity type:Individual
Prefix:DR
First Name:JERRY
Middle Name:E
Last Name:BOTTS
Suffix:
Gender:M
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:131 FOREST DR
Mailing Address - Street 2:
Mailing Address - City:CARL JUNCTION
Mailing Address - State:MO
Mailing Address - Zip Code:64834-9613
Mailing Address - Country:US
Mailing Address - Phone:417-624-6922
Mailing Address - Fax:
Practice Address - Street 1:102 S MAIN ST
Practice Address - Street 2:
Practice Address - City:CARL JUNCTION
Practice Address - State:MO
Practice Address - Zip Code:64834-1000
Practice Address - Country:US
Practice Address - Phone:417-649-7021
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO044270183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist