Provider Demographics
NPI:1013383165
Name:BOULOS, ANDREW (PHARMD)
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:
Last Name:BOULOS
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 1:421 RYDERS LN
Mailing Address - Street 2:
Mailing Address - City:EAST BRUNSWICK
Mailing Address - State:NJ
Mailing Address - Zip Code:08816-2700
Mailing Address - Country:US
Mailing Address - Phone:732-254-6609
Mailing Address - Fax:
Practice Address - Street 1:421 RYDERS LN
Practice Address - Street 2:
Practice Address - City:EAST BRUNSWICK
Practice Address - State:NJ
Practice Address - Zip Code:08816-2700
Practice Address - Country:US
Practice Address - Phone:732-254-6609
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-12
Last Update Date:2015-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RI03721400183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist