Provider Demographics
NPI:1679230031
Name:BOURQUE, CLARIVEL (RPH)
Entity Type:Individual
Prefix:
First Name:CLARIVEL
Middle Name:
Last Name:BOURQUE
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:258 N SHANKS ST
Mailing Address - Street 2:
Mailing Address - City:CLUTE
Mailing Address - State:TX
Mailing Address - Zip Code:77531-4128
Mailing Address - Country:US
Mailing Address - Phone:979-341-3704
Mailing Address - Fax:
Practice Address - Street 1:905 N GULF BLVD
Practice Address - Street 2:
Practice Address - City:FREEPORT
Practice Address - State:TX
Practice Address - Zip Code:77541-3907
Practice Address - Country:US
Practice Address - Phone:281-824-1470
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-19
Last Update Date:2021-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX69492183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist