Provider Demographics
NPI:1104391085
Name:BOUVIER, JASON MICHAEL (CPHT)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:MICHAEL
Last Name:BOUVIER
Suffix:
Gender:M
Credentials:CPHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2384 WHEELESS RD
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30906-5404
Mailing Address - Country:US
Mailing Address - Phone:706-836-7547
Mailing Address - Fax:
Practice Address - Street 1:403 FURYS FERRY RD
Practice Address - Street 2:
Practice Address - City:MARTINEZ
Practice Address - State:GA
Practice Address - Zip Code:30907-9038
Practice Address - Country:US
Practice Address - Phone:706-650-3665
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-08
Last Update Date:2024-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPHTC066137183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician