Provider Demographics
NPI:1518620525
Name:BOURQUEIN, MATTHEW (PHARMD)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:BOURQUEIN
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1600 E TIPTON ST
Mailing Address - Street 2:
Mailing Address - City:SEYMOUR
Mailing Address - State:IN
Mailing Address - Zip Code:47274-3560
Mailing Address - Country:US
Mailing Address - Phone:812-522-5252
Mailing Address - Fax:812-522-6152
Practice Address - Street 1:1600 E TIPTON ST
Practice Address - Street 2:
Practice Address - City:SEYMOUR
Practice Address - State:IN
Practice Address - Zip Code:47274-3560
Practice Address - Country:US
Practice Address - Phone:812-522-5252
Practice Address - Fax:812-522-6152
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-17
Last Update Date:2021-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26029257A1835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy SpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN26029257AOtherINDIANA PHARMACIST LICENSE