Provider Demographics
NPI:1386126118
Name:KOUSOULIS, PANAGIOTA (RPH)
Entity type:Individual
Prefix:MRS
First Name:PANAGIOTA
Middle Name:
Last Name:KOUSOULIS
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:96 JACOBUS AVE
Mailing Address - Street 2:
Mailing Address - City:LITTLE FALLS
Mailing Address - State:NJ
Mailing Address - Zip Code:07424-2305
Mailing Address - Country:US
Mailing Address - Phone:732-692-2784
Mailing Address - Fax:800-815-6808
Practice Address - Street 1:41 SPRING ST
Practice Address - Street 2:
Practice Address - City:NEW PROVIDENCE
Practice Address - State:NJ
Practice Address - Zip Code:07974-1143
Practice Address - Country:US
Practice Address - Phone:732-692-2784
Practice Address - Fax:800-815-6808
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-29
Last Update Date:2018-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RI024062001835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist