Provider Demographics
NPI:1417837022
Name:BOLOUS, LAUREN ELAINA-EMAD
Entity type:Individual
Prefix:
First Name:LAUREN
Middle Name:ELAINA-EMAD
Last Name:BOLOUS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7029 MARTANO PL
Mailing Address - Street 2:
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91701-9211
Mailing Address - Country:US
Mailing Address - Phone:909-367-0425
Mailing Address - Fax:
Practice Address - Street 1:9961 SIERRA AVE
Practice Address - Street 2:
Practice Address - City:FONTANA
Practice Address - State:CA
Practice Address - Zip Code:92335-6720
Practice Address - Country:US
Practice Address - Phone:833-574-2273
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-09-04
Last Update Date:2025-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA91251183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist