MEDICARE: ROBERT MATTHEW BOULWARE PHARM.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	53399	TX

General Provider Information

NPI Number	:	1790380921
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ROBERT MATTHEW BOULWARE PHARM.D.

Provider Business Mailing Address
First Line	:	432 PANCHASARP DR
Second Line	:
City	:	CROWLEY
State	:	TX
Zip	:	76036-1210
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5012 TRAIL LAKE DR
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76133-2028
Country	:	US
Telephone Number	:	817-292-1700
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/04/2020
Last Update Date	:	12/04/2020

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