Provider Demographics
NPI:1356941710
Name:BOTT, BRANDON M (PHARMD)
Entity type:Individual
Prefix:
First Name:BRANDON
Middle Name:M
Last Name:BOTT
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:730 E SAGINAW HWY
Mailing Address - Street 2:
Mailing Address - City:GRAND LEDGE
Mailing Address - State:MI
Mailing Address - Zip Code:48837-8411
Mailing Address - Country:US
Mailing Address - Phone:517-622-6810
Mailing Address - Fax:
Practice Address - Street 1:730 E SAGINAW HWY
Practice Address - Street 2:
Practice Address - City:GRAND LEDGE
Practice Address - State:MI
Practice Address - Zip Code:48837-8411
Practice Address - Country:US
Practice Address - Phone:517-622-6810
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-27
Last Update Date:2024-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302412671183500000X
IL051.3032612255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No183500000XPharmacy Service ProvidersPharmacist