Healthcare Provider Details

I. General information

NPI: 1033758925
Provider Name (Legal Business Name): FOUAD BOULBOL
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/26/2019
Last Update Date: 12/26/2019
Certification Date: 12/26/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

785 MEDICAL CENTER DRIVE WEST
CLOVIS CA
93611
US

IV. Provider business mailing address

785 MEDICAL CENTER DRIVE WEST
CLOVIS CA
93611
US

V. Phone/Fax

Practice location:
  • Phone: 559-387-1928
  • Fax:
Mailing address:
  • Phone: 559-387-1928
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License Number79726
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: