Provider Demographics
NPI:1235720731
Name:BOERGER, JOEL
Entity Type:Individual
Prefix:
First Name:JOEL
Middle Name:
Last Name:BOERGER
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:W344S9462 JERICHO DR
Mailing Address - Street 2:
Mailing Address - City:EAGLE
Mailing Address - State:WI
Mailing Address - Zip Code:53119-1691
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:15300 W GRANGE AVE
Practice Address - Street 2:
Practice Address - City:NEW BERLIN
Practice Address - State:WI
Practice Address - Zip Code:53151-7909
Practice Address - Country:US
Practice Address - Phone:262-599-7040
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-28
Last Update Date:2021-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI12813-401835P1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P1200XPharmacy Service ProvidersPharmacistPharmacotherapy