Provider Demographics
NPI:1326642547
Name:BOU, SAMBATH (RPH)
Entity Type:Individual
Prefix:
First Name:SAMBATH
Middle Name:
Last Name:BOU
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2019 LAKEVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:DRACUT
Mailing Address - State:MA
Mailing Address - Zip Code:01826-3224
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2019 LAKEVIEW AVE
Practice Address - Street 2:
Practice Address - City:DRACUT
Practice Address - State:MA
Practice Address - Zip Code:01826-3224
Practice Address - Country:US
Practice Address - Phone:978-957-6550
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-29
Last Update Date:2020-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPH233091183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist