Healthcare Provider Details

I. General information

NPI: 1700010667
Provider Name (Legal Business Name): DOUGLAS W BOUCHEY RPH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/06/2009
Last Update Date: 05/06/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

352 N ROSS ST
BEAVERTON MI
48612-8165
US

IV. Provider business mailing address

1905 CHURCHILL BLVD
MT PLEASANT MI
48858-9100
US

V. Phone/Fax

Practice location:
  • Phone: 989-435-7727
  • Fax: 989-435-3779
Mailing address:
  • Phone: 989-775-0828
  • Fax: 989-775-0828

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number5302023892
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number13803-040
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: