Provider Demographics
NPI:1972190254
Name:BOULANGER, AMIE NICOLE (RPH)
Entity Type:Individual
Prefix:MS
First Name:AMIE
Middle Name:NICOLE
Last Name:BOULANGER
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:65875 TURPIN RD
Mailing Address - Street 2:
Mailing Address - City:CASSOPOLIS
Mailing Address - State:MI
Mailing Address - Zip Code:49031-9630
Mailing Address - Country:US
Mailing Address - Phone:574-876-7177
Mailing Address - Fax:
Practice Address - Street 1:12850 ADAMS RD
Practice Address - Street 2:
Practice Address - City:GRANGER
Practice Address - State:IN
Practice Address - Zip Code:46530-7183
Practice Address - Country:US
Practice Address - Phone:574-807-8234
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-21
Last Update Date:2020-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26019763A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist