Provider Demographics
NPI:1851815005
Name:TAKLA, BOULES (RPH)
Entity type:Individual
Prefix:
First Name:BOULES
Middle Name:
Last Name:TAKLA
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7530 W CACTUS RD
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85381-5202
Mailing Address - Country:US
Mailing Address - Phone:623-334-4635
Mailing Address - Fax:623-334-4641
Practice Address - Street 1:7530 W CACTUS RD
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85381-5202
Practice Address - Country:US
Practice Address - Phone:623-334-4635
Practice Address - Fax:623-334-4641
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-31
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZS107305183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist