Provider Demographics
NPI:1154489136
Name:BOESEN, MARK D (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:D
Last Name:BOESEN
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:23620 N 20TH DR
Mailing Address - Street 2:STE 12
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85085-0621
Mailing Address - Country:US
Mailing Address - Phone:623-225-8772
Mailing Address - Fax:623-321-6694
Practice Address - Street 1:23620 N 20TH DR
Practice Address - Street 2:STE 12
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85085-0621
Practice Address - Country:US
Practice Address - Phone:623-225-8772
Practice Address - Fax:623-321-6694
Is Sole Proprietor?:No
Enumeration Date:2006-12-04
Last Update Date:2008-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ10941183500000X
VA202012069183500000X
MEPR4864183500000X
NV172501835P0018X
CO178921835P0018X
NC194601835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
No1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist