Provider Demographics
NPI:1265845267
Name:BOETTCHER, ERIC H
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:H
Last Name:BOETTCHER
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 1:2975 W MARKET ST
Mailing Address - Street 2:
Mailing Address - City:FAIRLAWN
Mailing Address - State:OH
Mailing Address - Zip Code:44333-3606
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2975 W MARKET ST
Practice Address - Street 2:
Practice Address - City:FAIRLAWN
Practice Address - State:OH
Practice Address - Zip Code:44333-3606
Practice Address - Country:US
Practice Address - Phone:330-867-8492
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-06
Last Update Date:2014-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH06009677183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist