Provider Demographics
NPI:1609241942
Name:BOULIS, MICHELINE
Entity Type:Individual
Prefix:
First Name:MICHELINE
Middle Name:
Last Name:BOULIS
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 1:5 CROFT PL
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10314-6501
Mailing Address - Country:US
Mailing Address - Phone:718-354-0957
Mailing Address - Fax:
Practice Address - Street 1:5 CROFT PL
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10314-6501
Practice Address - Country:US
Practice Address - Phone:718-354-0957
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-12-12
Last Update Date:2015-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY061238183500000X
NJ28RI03755500183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ28RI03755500OtherPHARMACIST LICENSE NUMBER
NY061238OtherPHARMACIST LICENSE NUMBER