MEDICARE: MICHAEL BOULOSWELSON FUAD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	PS62086	FL
2	183500000X	Pharmacist	PH100003270	DC

General Provider Information

NPI Number	:	1821691726
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICHAEL BOULOSWELSON FUAD

Provider Business Mailing Address
First Line	:	1748 TRIBUTORY LN
Second Line	:
City	:	PORT ORANGE
State	:	FL
Zip	:	32128-4049
Country	:	US
Telephone Number	:	347-691-9001
Fax Number	:

Provider Business Practice Location Address
First Line	:	1800 NEW SYMRNA
Second Line	:
City	:	NEW SYMERNA BEACH
State	:	FL
Zip	:	32168
Country	:	US
Telephone Number	:	386-428-1558
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/21/2020
Last Update Date	:	09/22/2022

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