MEDICARE: SAMEH HESHMAT WILLIAM AZIZ BOULES

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	85759	CA

General Provider Information

NPI Number	:	1124789474
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SAMEH HESHMAT WILLIAM AZIZ BOULES

Provider Business Mailing Address
First Line	:	1770 ADELAIDE ST APT 317
Second Line	:
City	:	CONCORD
State	:	CA
Zip	:	94520-3254
Country	:	US
Telephone Number	:	424-328-9784
Fax Number	:

Provider Business Practice Location Address
First Line	:	5437 CLAYTON RD
Second Line	:
City	:	CLAYTON
State	:	CA
Zip	:	94517-1039
Country	:	US
Telephone Number	:	925-672-1356
Fax Number	:

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

Provider Enumeration Date	:	01/07/2022
Last Update Date	:	01/07/2022

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