Provider Demographics
NPI:1952994717
Name:BOULOS, NANCY
Entity Type:Individual
Prefix:
First Name:NANCY
Middle Name:
Last Name:BOULOS
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 1:5616G OX RD
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX STATION
Mailing Address - State:VA
Mailing Address - Zip Code:22039-1018
Mailing Address - Country:US
Mailing Address - Phone:571-404-0007
Mailing Address - Fax:
Practice Address - Street 1:5616G OX RD
Practice Address - Street 2:
Practice Address - City:FAIRFAX STATION
Practice Address - State:VA
Practice Address - Zip Code:22039-1018
Practice Address - Country:US
Practice Address - Phone:571-404-0007
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-12
Last Update Date:2021-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202211927183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist