Provider Demographics
NPI:1629367099
Name:BOUDREAUX, BRENT F
Entity Type:Individual
Prefix:MR
First Name:BRENT
Middle Name:F
Last Name:BOUDREAUX
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 1:20901 E SMOKY HILL RD
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:CO
Mailing Address - Zip Code:80015-5184
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:20901 E SMOKY HILL RD
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80015-5184
Practice Address - Country:US
Practice Address - Phone:303-400-0627
Practice Address - Fax:303-400-0633
Is Sole Proprietor?:No
Enumeration Date:2011-04-06
Last Update Date:2011-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO14546183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist