Provider Demographics
NPI:1932700796
Name:BOUDREAU, JOE (RPH)
Entity Type:Individual
Prefix:
First Name:JOE
Middle Name:
Last Name:BOUDREAU
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 1:2610 N PROSPECT AVE
Mailing Address - Street 2:
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61822-1251
Mailing Address - Country:US
Mailing Address - Phone:217-352-1490
Mailing Address - Fax:
Practice Address - Street 1:2610 N PROSPECT AVE
Practice Address - Street 2:
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61822-1251
Practice Address - Country:US
Practice Address - Phone:217-352-1490
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-06
Last Update Date:2020-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051.298005183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist