Healthcare Provider Details

I. General information

NPI: 1598688657
Provider Name (Legal Business Name): ROSE BOUDREAU
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/04/2026
Last Update Date: 08/04/2026
Certification Date: 08/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1101 VETERANS DR
LEXINGTON KY
40502-2235
US

IV. Provider business mailing address

270 LANCER DR APT 319
NICHOLASVILLE KY
40356-2157
US

V. Phone/Fax

Practice location:
  • Phone: 859-233-4511
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number025971
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: