Provider Demographics
NPI:1659713691
Name:BOORTZ, JEROME PAUL (RPH)
Entity Type:Individual
Prefix:MR
First Name:JEROME
Middle Name:PAUL
Last Name:BOORTZ
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9366 STATE HIGHWAY 16
Mailing Address - Street 2:
Mailing Address - City:ONALASKA
Mailing Address - State:WI
Mailing Address - Zip Code:54650
Mailing Address - Country:US
Mailing Address - Phone:608-781-5404
Mailing Address - Fax:608-783-4966
Practice Address - Street 1:9366 STATE ROAD 16
Practice Address - Street 2:
Practice Address - City:ONALASKA
Practice Address - State:WI
Practice Address - Zip Code:54650-8526
Practice Address - Country:US
Practice Address - Phone:608-781-5404
Practice Address - Fax:608-783-4966
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-18
Last Update Date:2013-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI9192183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist