MEDICARE: MRS. PANAGIOTA KOUSOULIS RPH

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	1835P0018X	Pharmacist Clinician (PhC)/ Clinical Pharmacy Specialist	28RI02406200	NJ

General Provider Information

NPI Number	:	1386126118
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. PANAGIOTA KOUSOULIS RPH

Provider Business Mailing Address
First Line	:	96 JACOBUS AVE
Second Line	:
City	:	LITTLE FALLS
State	:	NJ
Zip	:	07424-2305
Country	:	US
Telephone Number	:	732-692-2784
Fax Number	:	800-815-6808

Provider Business Practice Location Address
First Line	:	41 SPRING ST
Second Line	:
City	:	NEW PROVIDENCE
State	:	NJ
Zip	:	07974-1143
Country	:	US
Telephone Number	:	732-692-2784
Fax Number	:	800-815-6808

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

Provider Enumeration Date	:	08/29/2018
Last Update Date	:	08/29/2018

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