Provider Demographics
NPI:1710464797
Name:BOUCHER, DYLAN P
Entity Type:Individual
Prefix:
First Name:DYLAN
Middle Name:P
Last Name:BOUCHER
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 1:13 EVELYN ST
Mailing Address - Street 2:
Mailing Address - City:HOOKSETT
Mailing Address - State:NH
Mailing Address - Zip Code:03106-2183
Mailing Address - Country:US
Mailing Address - Phone:603-860-3415
Mailing Address - Fax:
Practice Address - Street 1:1 GLENWOOD AVE
Practice Address - Street 2:
Practice Address - City:DOVER
Practice Address - State:NH
Practice Address - Zip Code:03820-2406
Practice Address - Country:US
Practice Address - Phone:603-749-4136
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-23
Last Update Date:2018-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NHPHCY-04468183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist