Provider Demographics
NPI:1275823940
Name:BOUDREAU, TRACIE (RPH)
Entity Type:Individual
Prefix:MRS
First Name:TRACIE
Middle Name:
Last Name:BOUDREAU
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:807 PAINE RD
Mailing Address - Street 2:
Mailing Address - City:NORTH ATTLEBORO
Mailing Address - State:MA
Mailing Address - Zip Code:02760-6218
Mailing Address - Country:US
Mailing Address - Phone:508-643-9557
Mailing Address - Fax:
Practice Address - Street 1:1099 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:SOUTH ATTLEBORO
Practice Address - State:MA
Practice Address - Zip Code:02703-7944
Practice Address - Country:US
Practice Address - Phone:508-399-8070
Practice Address - Fax:508-761-6150
Is Sole Proprietor?:No
Enumeration Date:2011-04-14
Last Update Date:2011-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPH22832183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist