Provider Demographics
NPI:1518244649
Name:BOUDREAU, MICHAEL
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:BOUDREAU
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 1:175 HIGH ST
Mailing Address - Street 2:
Mailing Address - City:ELLSWORTH
Mailing Address - State:ME
Mailing Address - Zip Code:04605-1730
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:175 HIGH ST
Practice Address - Street 2:
Practice Address - City:ELLSWORTH
Practice Address - State:ME
Practice Address - Zip Code:04605-1730
Practice Address - Country:US
Practice Address - Phone:207-669-3005
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-11-03
Last Update Date:2011-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPR4615183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist