Healthcare Provider Details

I. General information

NPI: 1669988457
Provider Name (Legal Business Name): MARY BOULES
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/16/2017
Last Update Date: 12/16/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3105 RANCHO VISTA BLVD
PALMDALE CA
93551-4822
US

IV. Provider business mailing address

40742 OAKMONT CT
PALMDALE CA
93551-5641
US

V. Phone/Fax

Practice location:
  • Phone: 661-538-1601
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number76501
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: