MEDICARE: OLIVE EDWINA BOTOR PHARMD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	52505	TX

General Provider Information

NPI Number	:	1376882167
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	OLIVE EDWINA BOTOR PHARMD

Provider Business Mailing Address
First Line	:	1302 N VIRGINIA ST
Second Line	:
City	:	PORT LAVACA
State	:	TX
Zip	:	77979-2509
Country	:	US
Telephone Number	:	361-552-7451
Fax Number	:	361-552-7594

Provider Business Practice Location Address
First Line	:	1302 N VIRGINIA ST
Second Line	:
City	:	PORT LAVACA
State	:	TX
Zip	:	77979-2509
Country	:	US
Telephone Number	:	361-552-7451
Fax Number	:	361-552-7594

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/14/2013
Last Update Date	:	02/14/2013

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