Provider Demographics
NPI:1922498484
Name:BOSLEM, HEATHER
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:
Last Name:BOSLEM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9833 N ALPINE RD
Mailing Address - Street 2:
Mailing Address - City:MACHESNEY PARK
Mailing Address - State:IL
Mailing Address - Zip Code:61115-1681
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1016 EMERALD LN
Practice Address - Street 2:
Practice Address - City:MACHESNEY PARK
Practice Address - State:IL
Practice Address - Zip Code:61115-2130
Practice Address - Country:US
Practice Address - Phone:815-289-8435
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-02-04
Last Update Date:2015-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL049172268183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician