Healthcare Provider Details

I. General information

NPI: 1457271512
Provider Name (Legal Business Name): STACEY KRISTEN BOUDREAUX PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/20/2026
Last Update Date: 07/20/2026
Certification Date: 07/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3850 DUTHIE BLVD
LEWISTON ID
83501-7045
US

IV. Provider business mailing address

3850 DUTHIE BLVD
LEWISTON ID
83501-7045
US

V. Phone/Fax

Practice location:
  • Phone: 303-550-5189
  • Fax:
Mailing address:
  • Phone: 303-550-5189
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberP7143
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: