Provider Demographics
NPI:1568948743
Name:BOLDUC, SKYLAR REID (PHARMACIST)
Entity Type:Individual
Prefix:
First Name:SKYLAR
Middle Name:REID
Last Name:BOLDUC
Suffix:
Gender:M
Credentials:PHARMACIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1620 CRABAPPLE LN
Mailing Address - Street 2:
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61822-3313
Mailing Address - Country:US
Mailing Address - Phone:309-714-2511
Mailing Address - Fax:
Practice Address - Street 1:104 E SOUTHLINE RD
Practice Address - Street 2:
Practice Address - City:TUSCOLA
Practice Address - State:IL
Practice Address - Zip Code:61953-2075
Practice Address - Country:US
Practice Address - Phone:217-351-8497
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-11
Last Update Date:2021-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2016028564183500000X
IL051299700183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist