Provider Demographics
NPI:1871089078
Name:BOTROS, DALIA MOHSEN AZIZ
Entity type:Individual
Prefix:
First Name:DALIA
Middle Name:MOHSEN AZIZ
Last Name:BOTROS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1656 STRATHMORE WAY
Mailing Address - Street 2:
Mailing Address - City:ROCKLIN
Mailing Address - State:CA
Mailing Address - Zip Code:95765-5488
Mailing Address - Country:US
Mailing Address - Phone:650-863-2450
Mailing Address - Fax:
Practice Address - Street 1:1656 STRATHMORE WAY
Practice Address - Street 2:
Practice Address - City:ROCKLIN
Practice Address - State:CA
Practice Address - Zip Code:95765-5488
Practice Address - Country:US
Practice Address - Phone:650-863-2450
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-11
Last Update Date:2018-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA78356183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist