Healthcare Provider Details

I. General information

NPI: 1740577832
Provider Name (Legal Business Name): ANNE VINHAN BOULOM RPH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/08/2011
Last Update Date: 07/08/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

695 W HERNDON AVE T-2018
CLOVIS CA
93612-0104
US

IV. Provider business mailing address

695 W HERNDON AVE T-2018
CLOVIS CA
93612-0104
US

V. Phone/Fax

Practice location:
  • Phone: 559-321-0010
  • Fax: 559-326-1351
Mailing address:
  • Phone: 559-321-0010
  • Fax: 559-326-1351

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number55362
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: