Provider Demographics
NPI:1578904207
Name:BOUGH, MARY (PHARMD, RPH)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:BOUGH
Suffix:
Gender:F
Credentials:PHARMD, RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:115 N 19TH AVE
Mailing Address - Street 2:
Mailing Address - City:BOZEMAN
Mailing Address - State:MT
Mailing Address - Zip Code:59718-4072
Mailing Address - Country:US
Mailing Address - Phone:406-587-9252
Mailing Address - Fax:406-586-6803
Practice Address - Street 1:115 N 19TH AVE
Practice Address - Street 2:
Practice Address - City:BOZEMAN
Practice Address - State:MT
Practice Address - Zip Code:59718-4072
Practice Address - Country:US
Practice Address - Phone:406-587-9252
Practice Address - Fax:406-586-6803
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-10
Last Update Date:2013-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT3978183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist