Provider Demographics
NPI:1124789474
Name:BOULES, SAMEH HESHMAT WILLIAM AZIZ
Entity type:Individual
Prefix:
First Name:SAMEH
Middle Name:HESHMAT WILLIAM AZIZ
Last Name:BOULES
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1770 ADELAIDE ST APT 317
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:CA
Mailing Address - Zip Code:94520-3254
Mailing Address - Country:US
Mailing Address - Phone:424-328-9784
Mailing Address - Fax:
Practice Address - Street 1:5437 CLAYTON RD
Practice Address - Street 2:
Practice Address - City:CLAYTON
Practice Address - State:CA
Practice Address - Zip Code:94517-1039
Practice Address - Country:US
Practice Address - Phone:925-672-1356
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-07
Last Update Date:2022-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA85759183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist