Provider Demographics
NPI:1861119398
Name:BOTROS, EMAD
Entity type:Individual
Prefix:
First Name:EMAD
Middle Name:
Last Name:BOTROS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:ED
Other - Middle Name:
Other - Last Name:BOTROS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:142 W H ST
Mailing Address - Street 2:
Mailing Address - City:COLTON
Mailing Address - State:CA
Mailing Address - Zip Code:92324-2923
Mailing Address - Country:US
Mailing Address - Phone:909-825-1950
Mailing Address - Fax:909-825-9330
Practice Address - Street 1:142 W H ST
Practice Address - Street 2:
Practice Address - City:COLTON
Practice Address - State:CA
Practice Address - Zip Code:92324-2923
Practice Address - Country:US
Practice Address - Phone:909-825-1950
Practice Address - Fax:909-825-9330
Is Sole Proprietor?:No
Enumeration Date:2022-10-25
Last Update Date:2022-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA50080183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist