Provider Demographics
NPI:1659710747
Name:BOULDIN, JAMESON MICHAEL
Entity Type:Individual
Prefix:
First Name:JAMESON
Middle Name:MICHAEL
Last Name:BOULDIN
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 1:5521 CHARLOTTE PIKE
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37209-3210
Mailing Address - Country:US
Mailing Address - Phone:615-446-3791
Mailing Address - Fax:615-446-5985
Practice Address - Street 1:5521 CHARLOTTE PIKE
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37209-3210
Practice Address - Country:US
Practice Address - Phone:615-446-3791
Practice Address - Fax:615-446-5985
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-21
Last Update Date:2013-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN37404183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist