Provider Demographics
NPI:1558579193
Name:BOUCHER, BRYAN DAVID (RPH)
Entity Type:Individual
Prefix:
First Name:BRYAN
Middle Name:DAVID
Last Name:BOUCHER
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:55 PARTRIDGE LN
Mailing Address - Street 2:
Mailing Address - City:CHESTER
Mailing Address - State:NH
Mailing Address - Zip Code:03036-8103
Mailing Address - Country:US
Mailing Address - Phone:603-887-7813
Mailing Address - Fax:
Practice Address - Street 1:1631 ELM ST
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:NH
Practice Address - Zip Code:03101-1207
Practice Address - Country:US
Practice Address - Phone:603-623-4393
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-18
Last Update Date:2010-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NHR1903183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist