Provider Demographics
NPI:1881498491
Name:BOUGHNER, TROY DAVID (PHARMD)
Entity type:Individual
Prefix:
First Name:TROY
Middle Name:DAVID
Last Name:BOUGHNER
Suffix:
Gender:
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16 OLD WHITMORE AVE SE APT 317
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24016-1232
Mailing Address - Country:US
Mailing Address - Phone:304-904-2788
Mailing Address - Fax:
Practice Address - Street 1:3970 VALLEY GATEWAY BLVD
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24012-6773
Practice Address - Country:US
Practice Address - Phone:540-977-6482
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-04-02
Last Update Date:2025-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA90782183500000X
VA0202220648183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist