Provider Demographics
NPI:1407286032
Name:BOHLMAN, CHAD
Entity Type:Individual
Prefix:
First Name:CHAD
Middle Name:
Last Name:BOHLMAN
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 1:220 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MONMOUTH
Mailing Address - State:IL
Mailing Address - Zip Code:61462-1741
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:220 N MAIN ST
Practice Address - Street 2:
Practice Address - City:MONMOUTH
Practice Address - State:IL
Practice Address - Zip Code:61462-1741
Practice Address - Country:US
Practice Address - Phone:309-734-5196
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-18
Last Update Date:2013-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051293945183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist