Provider Demographics
NPI:1508452723
Name:GENDY, BOUTAMINA
Entity Type:Individual
Prefix:
First Name:BOUTAMINA
Middle Name:
Last Name:GENDY
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 1:4015 WHEAT HARVEST LN
Mailing Address - Street 2:
Mailing Address - City:KATY
Mailing Address - State:TX
Mailing Address - Zip Code:77494-6740
Mailing Address - Country:US
Mailing Address - Phone:508-244-9740
Mailing Address - Fax:
Practice Address - Street 1:4015 WHEAT HARVEST LN
Practice Address - Street 2:
Practice Address - City:KATY
Practice Address - State:TX
Practice Address - Zip Code:77494-6740
Practice Address - Country:US
Practice Address - Phone:082-449-7405
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-13
Last Update Date:2020-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX65817183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist