Provider Demographics
NPI:1831474253
Name:BOSSE, CARLTON O
Entity Type:Individual
Prefix:
First Name:CARLTON
Middle Name:O
Last Name:BOSSE
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 1:209 S ALLOY DR
Mailing Address - Street 2:
Mailing Address - City:FENTON
Mailing Address - State:MI
Mailing Address - Zip Code:48430
Mailing Address - Country:US
Mailing Address - Phone:810-714-7456
Mailing Address - Fax:616-878-8850
Practice Address - Street 1:209 S ALLOY DR
Practice Address - Street 2:
Practice Address - City:FENTON
Practice Address - State:MI
Practice Address - Zip Code:48430-3401
Practice Address - Country:US
Practice Address - Phone:810-714-7456
Practice Address - Fax:616-878-8850
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-17
Last Update Date:2011-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302027521183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist