Provider Demographics
NPI:1699390591
Name:BOUCKAERT, MICHAEL DONALD (RPH)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:DONALD
Last Name:BOUCKAERT
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 1:4578 FRASER RD
Mailing Address - Street 2:
Mailing Address - City:BAY CITY
Mailing Address - State:MI
Mailing Address - Zip Code:48706-9423
Mailing Address - Country:US
Mailing Address - Phone:989-798-1349
Mailing Address - Fax:989-439-1613
Practice Address - Street 1:1900 COLUMBUS AVE
Practice Address - Street 2:
Practice Address - City:BAY CITY
Practice Address - State:MI
Practice Address - Zip Code:48708-6831
Practice Address - Country:US
Practice Address - Phone:989-894-3744
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-16
Last Update Date:2020-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302025032183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist