Provider Demographics
NPI:1013906932
Name:BOURQUE, MICHAEL R (BS, PHARMD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:R
Last Name:BOURQUE
Suffix:
Gender:M
Credentials:BS, PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 BRANDYWINE DR
Mailing Address - Street 2:
Mailing Address - City:HOOKSETT
Mailing Address - State:NH
Mailing Address - Zip Code:03106-1303
Mailing Address - Country:US
Mailing Address - Phone:603-485-7261
Mailing Address - Fax:
Practice Address - Street 1:315 W MAIN ST
Practice Address - Street 2:
Practice Address - City:HILLSBORO
Practice Address - State:NH
Practice Address - Zip Code:03244-5234
Practice Address - Country:US
Practice Address - Phone:603-464-5678
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH3343183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist