Provider Demographics
NPI:1740564434
Name:BOULUS, AMGAD SHAWKY (RPH)
Entity Type:Individual
Prefix:MR
First Name:AMGAD
Middle Name:SHAWKY
Last Name:BOULUS
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 1:1418 E PROSPERITY AVE
Mailing Address - Street 2:
Mailing Address - City:TULARE
Mailing Address - State:CA
Mailing Address - Zip Code:93274-8054
Mailing Address - Country:US
Mailing Address - Phone:559-684-7963
Mailing Address - Fax:559-684-7967
Practice Address - Street 1:1418 E PROSPERITY AVE
Practice Address - Street 2:
Practice Address - City:TULARE
Practice Address - State:CA
Practice Address - Zip Code:93274-8054
Practice Address - Country:US
Practice Address - Phone:559-684-7963
Practice Address - Fax:559-684-7967
Is Sole Proprietor?:No
Enumeration Date:2011-09-29
Last Update Date:2013-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA65170183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist