Provider Demographics
NPI:1215540620
Name:BOULOS, JUSTINA BAHAA
Entity Type:Individual
Prefix:
First Name:JUSTINA
Middle Name:BAHAA
Last Name:BOULOS
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 1:22 E SAINT GEORGES AVE
Mailing Address - Street 2:
Mailing Address - City:LINDEN
Mailing Address - State:NJ
Mailing Address - Zip Code:07036-2936
Mailing Address - Country:US
Mailing Address - Phone:908-925-0704
Mailing Address - Fax:
Practice Address - Street 1:22 E SAINT GEORGES AVE
Practice Address - Street 2:
Practice Address - City:LINDEN
Practice Address - State:NJ
Practice Address - Zip Code:07036-2936
Practice Address - Country:US
Practice Address - Phone:908-925-0704
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-25
Last Update Date:2020-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RI04104900183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist