| Entity Name: | PETER BOTROS PHARMACY, INC. |
| Jurisdiction: | FLORIDA |
| Filing Type: | Domestic Profit |
| Status: | Active |
| Date Filed: | 15 Oct 2007 (17 years ago) |
| Last Event: | AMENDMENT |
| Event Date Filed: | 21 Nov 2016 (8 years ago) |
| Document Number: | P07000113683 |
| FEI/EIN Number | 412255325 |
| Address: | 121 Victoria Commons Blvd., 102, DELAND, FL, 32724, US |
| Mail Address: | 121 Victoria Commons Blvd., 102, DELAND, FL, 32724, US |
| ZIP code: | 32724 |
| County: | Volusia |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1982864831 | 2008-06-13 | 2019-08-02 | 121 VICTORIA COMMONS BLVD, SUITE #102, DELAND, FL, 32724, US | 121 VICTORIA COMMONS BLVD, SUITE #102, DELAND, FL, 32724, US | |||||||||||||||||||||||||||||||||||||
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| Phone | +1 386-734-8477 |
| Fax | 3867348488 |
Authorized person
| Name | MICHAEL SHALBY KAMEL |
| Role | PRESIDENT & OWNER |
| Phone | 3867348477 |
Taxonomy
| Taxonomy Code | 333600000X - Pharmacy |
| Is Primary | No |
| Taxonomy Code | 3336C0003X - Community/Retail Pharmacy |
| License Number | PH23396 |
| State | FL |
| Is Primary | Yes |
| Taxonomy Code | 3336L0003X - Long Term Care Pharmacy |
| Is Primary | No |
Other Provider Identifiers
| Issuer | PK |
| Number | 2128204 |
| Issuer | MEDICAID |
| Number | 000362700 |
| State | FL |
| Name | Role | Address |
|---|---|---|
| KAMEL MICHAEL S | Agent | 6631 MERRY VALE LANE, PORT ORANGE, FL, 32128 |
| Name | Role | Address |
|---|---|---|
| KAMEL MICHAEL S | President | 121 Victoria Commons Blvd., DELAND, FL, 32724 |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| CHANGE OF PRINCIPAL ADDRESS | 2020-03-09 | 121 Victoria Commons Blvd., 102, DELAND, FL 32724 | No data |
| CHANGE OF MAILING ADDRESS | 2020-03-09 | 121 Victoria Commons Blvd., 102, DELAND, FL 32724 | No data |
| REGISTERED AGENT ADDRESS CHANGED | 2016-11-21 | 6631 MERRY VALE LANE, 102, PORT ORANGE, FL 32128 | No data |
| AMENDMENT | 2016-11-21 | No data | No data |
| REGISTERED AGENT NAME CHANGED | 2016-11-21 | KAMEL, MICHAEL S. | No data |
| AMENDMENT | 2016-02-18 | No data | No data |
| AMENDMENT | 2016-02-10 | No data | No data |
| AMENDMENT | 2015-09-04 | No data | No data |
| AMENDMENT | 2009-01-06 | No data | No data |
| Name | Date |
|---|---|
| ANNUAL REPORT | 2024-04-20 |
| ANNUAL REPORT | 2023-04-20 |
| ANNUAL REPORT | 2022-04-26 |
| ANNUAL REPORT | 2021-04-22 |
| ANNUAL REPORT | 2020-03-09 |
| ANNUAL REPORT | 2019-04-18 |
| ANNUAL REPORT | 2018-04-16 |
| ANNUAL REPORT | 2017-04-21 |
| Amendment | 2016-11-21 |
| ANNUAL REPORT | 2016-03-24 |
Date of last update: 01 Feb 2025
Sources: Florida Department of State
