Healthcare Provider Details

I. General information

NPI: 1538075296
Provider Name (Legal Business Name): AUSTEN BOUCHER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/21/2026
Last Update Date: 08/21/2026
Certification Date: 08/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

213 2ND AVE NE
ROLLA ND
58367-7153
US

IV. Provider business mailing address

PO BOX 53
ROCKLAKE ND
58365-0053
US

V. Phone/Fax

Practice location:
  • Phone: 701-477-3161
  • Fax:
Mailing address:
  • Phone: 701-477-3161
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberRPH6746
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: