Provider Demographics
NPI:1053744078
Name:BOULOS, MAIRYANA GEORGE (PHARMD)
Entity type:Individual
Prefix:
First Name:MAIRYANA
Middle Name:GEORGE
Last Name:BOULOS
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14427 GRAYLAND AVENUE
Mailing Address - Street 2:
Mailing Address - City:NORWALK
Mailing Address - State:CA
Mailing Address - Zip Code:90650
Mailing Address - Country:US
Mailing Address - Phone:562-900-1556
Mailing Address - Fax:
Practice Address - Street 1:14427 GRAYLAND AVE
Practice Address - Street 2:
Practice Address - City:NORWALK
Practice Address - State:CA
Practice Address - Zip Code:90650-4951
Practice Address - Country:US
Practice Address - Phone:562-900-1556
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-13
Last Update Date:2013-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA67969183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist