Provider Demographics
NPI:1033597992
Name:BOULES, ESSAM NASHAT FARAH
Entity Type:Individual
Prefix:
First Name:ESSAM
Middle Name:NASHAT FARAH
Last Name:BOULES
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4247 S MOONEY BLVD
Mailing Address - Street 2:
Mailing Address - City:VISALIA
Mailing Address - State:CA
Mailing Address - Zip Code:93277-9146
Mailing Address - Country:US
Mailing Address - Phone:559-749-0740
Mailing Address - Fax:
Practice Address - Street 1:4247 S MOONEY BLVD
Practice Address - Street 2:
Practice Address - City:VISALIA
Practice Address - State:CA
Practice Address - Zip Code:93277-9146
Practice Address - Country:US
Practice Address - Phone:559-749-0740
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-05-12
Last Update Date:2015-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA66633183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist