Provider Demographics
NPI:1114179918
Name:BOEHLAND, BURNELL JASON
Entity Type:Individual
Prefix:MR
First Name:BURNELL
Middle Name:JASON
Last Name:BOEHLAND
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3013 NW STEWART PKWY
Mailing Address - Street 2:
Mailing Address - City:ROSEBURG
Mailing Address - State:OR
Mailing Address - Zip Code:97471-1612
Mailing Address - Country:US
Mailing Address - Phone:541-957-9236
Mailing Address - Fax:
Practice Address - Street 1:3013 NW STEWART PKWY
Practice Address - Street 2:
Practice Address - City:ROSEBURG
Practice Address - State:OR
Practice Address - Zip Code:97471-1612
Practice Address - Country:US
Practice Address - Phone:541-957-9236
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-13
Last Update Date:2018-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR9895183500000X
ORRPH-00098951835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
No183500000XPharmacy Service ProvidersPharmacist