Healthcare Provider Details

I. General information

NPI: 1679014245
Provider Name (Legal Business Name): CHASE BOUCHER PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/16/2017
Last Update Date: 12/01/2020
Certification Date: 12/01/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1272 TOWN AND COUNTRY CROSSING DR
CHESTERFIELD MO
63017-0605
US

IV. Provider business mailing address

1272 TOWN AND COUNTRY CROSSING DR
CHESTERFIELD MO
63017-0605
US

V. Phone/Fax

Practice location:
  • Phone: 636-591-0235
  • Fax:
Mailing address:
  • Phone: 636-591-0235
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number2016013122
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: