Provider Demographics
NPI:1265754360
Name:BOUCHARD, JEFFREY ROBERT (RPH)
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:ROBERT
Last Name:BOUCHARD
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 1:410 WADHAMS ST
Mailing Address - Street 2:
Mailing Address - City:OGDENSBURG
Mailing Address - State:NY
Mailing Address - Zip Code:13669-2120
Mailing Address - Country:US
Mailing Address - Phone:315-393-0031
Mailing Address - Fax:
Practice Address - Street 1:700 CANTON ST
Practice Address - Street 2:
Practice Address - City:OGDENSBURG
Practice Address - State:NY
Practice Address - Zip Code:13669-3836
Practice Address - Country:US
Practice Address - Phone:315-393-2440
Practice Address - Fax:315-393-1341
Is Sole Proprietor?:No
Enumeration Date:2010-02-17
Last Update Date:2010-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY031511-1183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist