Provider Demographics
NPI:1902231699
Name:BOULOS, DINA (RPH)
Entity Type:Individual
Prefix:
First Name:DINA
Middle Name:
Last Name:BOULOS
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26 ELM ST
Mailing Address - Street 2:
Mailing Address - City:EAST BRUNSWICK
Mailing Address - State:NJ
Mailing Address - Zip Code:08816-2339
Mailing Address - Country:US
Mailing Address - Phone:908-930-6670
Mailing Address - Fax:
Practice Address - Street 1:160 E 53RD ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10022-5243
Practice Address - Country:US
Practice Address - Phone:212-610-0117
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-12
Last Update Date:2013-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RI03452600183500000X
NY0558281835X0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835X0200XPharmacy Service ProvidersPharmacistOncology
No183500000XPharmacy Service ProvidersPharmacist