MEDICARE: CARRIE JEAN BOECKELMAN 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	11798-040	WI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	11798-040	OTHER	WI	PHARMACIST

General Provider Information

NPI Number	:	1407927718
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CARRIE JEAN BOECKELMAN RPH

Provider Business Mailing Address
First Line	:	5001 MONONA DRIVE
Second Line	:
City	:	MADISON
State	:	WI
Zip	:	53716
Country	:	US
Telephone Number	:	608-226-5039
Fax Number	:

Provider Business Practice Location Address
First Line	:	5001 MONONA DRIVE
Second Line	:
City	:	MADISON
State	:	WI
Zip	:	53716
Country	:	US
Telephone Number	:	608-226-5039
Fax Number	:

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

Provider Enumeration Date	:	11/10/2006
Last Update Date	:	07/08/2007

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