Provider Demographics
NPI:1063013142
Name:BOULAHBAL, SIHEM
Entity Type:Individual
Prefix:
First Name:SIHEM
Middle Name:
Last Name:BOULAHBAL
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 1:2080 N STATE ROUTE 50
Mailing Address - Street 2:
Mailing Address - City:BOURBONNAIS
Mailing Address - State:IL
Mailing Address - Zip Code:60914-4410
Mailing Address - Country:US
Mailing Address - Phone:815-937-5175
Mailing Address - Fax:815-937-5144
Practice Address - Street 1:2080 N STATE ROUTE 50
Practice Address - Street 2:
Practice Address - City:BOURBONNAIS
Practice Address - State:IL
Practice Address - Zip Code:60914-4410
Practice Address - Country:US
Practice Address - Phone:815-937-5175
Practice Address - Fax:815-937-5144
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-04
Last Update Date:2020-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051296239183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist