Provider Demographics
NPI:1871261933
Name:BOLANOS, PAUL SERRANO (RPH)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:SERRANO
Last Name:BOLANOS
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 1:5904 E MONO ST
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93727-5575
Mailing Address - Country:US
Mailing Address - Phone:559-241-4490
Mailing Address - Fax:559-459-6110
Practice Address - Street 1:290 N WAYTE LN FL 1
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93701-2124
Practice Address - Country:US
Practice Address - Phone:559-459-5044
Practice Address - Fax:559-459-6110
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-02
Last Update Date:2021-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA45794183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty