Provider Demographics
NPI:1164019048
Name:BOUCHER, CARL R (RPH)
Entity Type:Individual
Prefix:MR
First Name:CARL
Middle Name:R
Last Name:BOUCHER
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:39 FLORIDA AVE
Mailing Address - Street 2:
Mailing Address - City:BANGOR
Mailing Address - State:ME
Mailing Address - Zip Code:04401-3064
Mailing Address - Country:US
Mailing Address - Phone:207-942-8231
Mailing Address - Fax:207-942-1276
Practice Address - Street 1:383 WILSON ST
Practice Address - Street 2:
Practice Address - City:BREWER
Practice Address - State:ME
Practice Address - Zip Code:04412-1521
Practice Address - Country:US
Practice Address - Phone:207-989-8290
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-28
Last Update Date:2020-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPR5010183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist