Healthcare Provider Details

I. General information

NPI: 1720390313
Provider Name (Legal Business Name): JUSTIN WILLIAM BOUW PHARM.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2010
Last Update Date: 07/12/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1481 W 10TH ST
INDIANAPOLIS IN
46202-2803
US

IV. Provider business mailing address

12485 KEELEY CT
FISHERS IN
46038-3046
US

V. Phone/Fax

Practice location:
  • Phone: 317-988-4368
  • Fax:
Mailing address:
  • Phone: 765-346-7605
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License Number26023310A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: