Provider Demographics
NPI:1700010667
Name:BOUCHEY, DOUGLAS W (RPH)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:W
Last Name:BOUCHEY
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 1:1905 CHURCHILL BLVD
Mailing Address - Street 2:
Mailing Address - City:MT PLEASANT
Mailing Address - State:MI
Mailing Address - Zip Code:48858-9100
Mailing Address - Country:US
Mailing Address - Phone:989-775-0828
Mailing Address - Fax:989-775-0828
Practice Address - Street 1:352 N ROSS ST
Practice Address - Street 2:
Practice Address - City:BEAVERTON
Practice Address - State:MI
Practice Address - Zip Code:48612-8165
Practice Address - Country:US
Practice Address - Phone:989-435-7727
Practice Address - Fax:989-435-3779
Is Sole Proprietor?:No
Enumeration Date:2009-05-06
Last Update Date:2009-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302023892183500000X
WI13803-040183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist