Provider Demographics
NPI:1497180301
Name:BASLIOUS, RAOUF M (RPH)
Entity Type:Individual
Prefix:
First Name:RAOUF
Middle Name:M
Last Name:BASLIOUS
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2250 CALLE BELICIA
Mailing Address - Street 2:
Mailing Address - City:SAN DIMAS
Mailing Address - State:CA
Mailing Address - Zip Code:91773-4464
Mailing Address - Country:US
Mailing Address - Phone:909-599-9480
Mailing Address - Fax:
Practice Address - Street 1:120 E BONITA AVE
Practice Address - Street 2:
Practice Address - City:SAN DIMAS
Practice Address - State:CA
Practice Address - Zip Code:91773-3003
Practice Address - Country:US
Practice Address - Phone:909-305-4888
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-10
Last Update Date:2013-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARPH39233183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist