Provider Demographics
NPI:1225506843
Name:BOUCHARD, JAKE (PHARM-D)
Entity Type:Individual
Prefix:
First Name:JAKE
Middle Name:
Last Name:BOUCHARD
Suffix:
Gender:M
Credentials:PHARM-D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:37 CHESHIRE RD
Mailing Address - Street 2:
Mailing Address - City:PITTSFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01201-1814
Mailing Address - Country:US
Mailing Address - Phone:413-443-4486
Mailing Address - Fax:
Practice Address - Street 1:37 CHESHIRE RD
Practice Address - Street 2:
Practice Address - City:PITTSFIELD
Practice Address - State:MA
Practice Address - Zip Code:01201-1814
Practice Address - Country:US
Practice Address - Phone:413-443-4486
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-13
Last Update Date:2018-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPH238373183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist