MEDICARE: MATTHEW WILLIAM BOUCHARD B.S.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	16706	NV

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	016497	OTHER	KY	PHARMACIST LICENSE
2	P11976	OTHER	MS	PHARMACIST LICENSE
3	PD11738	OTHER	AR	PHARMACIST LICENSE
4	16706	OTHER	NV	PHARMACIST LICENSE
5	S019524	OTHER	AZ	PHARMACIST LICENSE
6	36982	OTHER	TN	PHARMACIST LICENSE
7	RPH-0012926	OTHER	OR	PHARMACIST LICENSE
8	14059	OTHER	NE	PHARMACIST LICENSE
9	202011979	OTHER	VA	PHARMACIST LICENSE
10	PST.019679	OTHER	LA	PHARMACIST LICENSE
11	20910	OTHER	MD	PHARMACIST LICENSE

General Provider Information

NPI Number	:	1215276902
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MATTHEW WILLIAM BOUCHARD B.S.

Provider Business Mailing Address
First Line	:	6380 POLARIS AVE UNIT B
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89118-3821
Country	:	US
Telephone Number	:	702-269-2005
Fax Number	:	702-269-4428

Provider Business Practice Location Address
First Line	:	6380 POLARIS AVE UNIT B
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89118-3821
Country	:	US
Telephone Number	:	702-269-2005
Fax Number	:	702-269-4428

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/31/2013
Last Update Date	:	01/27/2014

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