Provider Demographics
NPI:1336801661
Name:BOULES, MINA
Entity Type:Individual
Prefix:
First Name:MINA
Middle Name:
Last Name:BOULES
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:61 SPARTA AVE
Mailing Address - Street 2:
Mailing Address - City:SPARTA
Mailing Address - State:NJ
Mailing Address - Zip Code:07871-1867
Mailing Address - Country:US
Mailing Address - Phone:973-512-3131
Mailing Address - Fax:
Practice Address - Street 1:61 SPARTA AVE
Practice Address - Street 2:
Practice Address - City:SPARTA
Practice Address - State:NJ
Practice Address - Zip Code:07871-1867
Practice Address - Country:US
Practice Address - Phone:973-512-3131
Practice Address - Fax:973-512-3336
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-13
Last Update Date:2022-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RI04181000183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist