Provider Demographics
NPI:1235559881
Name:BOEHME, BRAD CRAIG
Entity Type:Individual
Prefix:MR
First Name:BRAD
Middle Name:CRAIG
Last Name:BOEHME
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 1:9775 SW GEMINI DR
Mailing Address - Street 2:STE 1
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97008-7148
Mailing Address - Country:US
Mailing Address - Phone:866-202-4014
Mailing Address - Fax:
Practice Address - Street 1:9775 SW GEMINI DR
Practice Address - Street 2:STE 1
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97008-7148
Practice Address - Country:US
Practice Address - Phone:866-202-4014
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-04-22
Last Update Date:2014-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR0008601183500000X
TX47988183500000X
NE13142183500000X
AZS015044183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist