Provider Demographics
NPI:1205115219
Name:BOTTOROFF, TENZIN
Entity type:Individual
Prefix:
First Name:TENZIN
Middle Name:
Last Name:BOTTOROFF
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1900 WOODLAND DR, STE A
Mailing Address - Street 2:WALGREENS #15153
Mailing Address - City:COOS BAY
Mailing Address - State:OR
Mailing Address - Zip Code:97420-2099
Mailing Address - Country:US
Mailing Address - Phone:541-267-4815
Mailing Address - Fax:541-267-4873
Practice Address - Street 1:1900 WOODLAND DR
Practice Address - Street 2:SUITE A
Practice Address - City:COOS-BAY
Practice Address - State:OR
Practice Address - Zip Code:97420-2099
Practice Address - Country:US
Practice Address - Phone:541-267-4815
Practice Address - Fax:541-267-4873
Is Sole Proprietor?:No
Enumeration Date:2011-08-08
Last Update Date:2011-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR0009818183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist