Provider Demographics
NPI:1548731714
Name:BOTROS, SAMUEL M (PHARMD)
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:M
Last Name:BOTROS
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 1:613 GRANDVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:RIDGEWOOD
Mailing Address - State:NY
Mailing Address - Zip Code:11385-2458
Mailing Address - Country:US
Mailing Address - Phone:347-825-7163
Mailing Address - Fax:
Practice Address - Street 1:520 E 70TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10021-9800
Practice Address - Country:US
Practice Address - Phone:347-825-7163
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-16
Last Update Date:2018-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY064214183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist