MEDICARE: MRS. TRACIE BOUDREAU RPH

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	PH22832	MA

General Provider Information

NPI Number	:	1275823940
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. TRACIE BOUDREAU RPH

Provider Business Mailing Address
First Line	:	807 PAINE RD
Second Line	:
City	:	NORTH ATTLEBORO
State	:	MA
Zip	:	02760-6218
Country	:	US
Telephone Number	:	508-643-9557
Fax Number	:

Provider Business Practice Location Address
First Line	:	1099 WASHINGTON ST
Second Line	:
City	:	SOUTH ATTLEBORO
State	:	MA
Zip	:	02703-7944
Country	:	US
Telephone Number	:	508-399-8070
Fax Number	:	508-761-6150

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

Provider Enumeration Date	:	04/14/2011
Last Update Date	:	04/14/2011

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