Healthcare Provider Details

I. General information

NPI: 1104391085
Provider Name (Legal Business Name): JASON MICHAEL BOUVIER CPHT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/08/2018
Last Update Date: 09/11/2025
Certification Date: 09/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

403 FURYS FERRY RD
MARTINEZ GA
30907-9038
US

IV. Provider business mailing address

2384 WHEELESS RD
AUGUSTA GA
30906-5404
US

V. Phone/Fax

Practice location:
  • Phone: 706-650-3665
  • Fax:
Mailing address:
  • Phone: 706-836-7547
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License NumberPHTC066137
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: