Provider Demographics
NPI:1366555948
Name:BOTTEMILLER, BRIAN (RPH)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:
Last Name:BOTTEMILLER
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 67
Mailing Address - Street 2:
Mailing Address - City:WILLOW CREEK
Mailing Address - State:CA
Mailing Address - Zip Code:95573-0067
Mailing Address - Country:US
Mailing Address - Phone:530-629-3144
Mailing Address - Fax:530-629-4303
Practice Address - Street 1:39050 HIGHWAY 299
Practice Address - Street 2:
Practice Address - City:WILLOW CREEK
Practice Address - State:CA
Practice Address - Zip Code:95573-0067
Practice Address - Country:US
Practice Address - Phone:530-629-3144
Practice Address - Fax:530-629-4303
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-16
Last Update Date:2016-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARPH37624183500000X
CA376241835P0018X, 183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
No183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CARPH37624OtherSTATE LIC.