Provider Demographics
NPI:1558641845
Name:BOONSTRA, JAMES GUILLERMO
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:GUILLERMO
Last Name:BOONSTRA
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 1:619 COURT RDG
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75703-5908
Mailing Address - Country:US
Mailing Address - Phone:903-245-0671
Mailing Address - Fax:
Practice Address - Street 1:619 COURT RDG
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75703-5908
Practice Address - Country:US
Practice Address - Phone:903-245-0671
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-18
Last Update Date:2011-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX33748183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist