MEDICARE: SKYLAR REID BOLDUC PHARMACIST

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	2016028564	MO
2	183500000X	Pharmacist	051299700	IL

General Provider Information

NPI Number	:	1568948743
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SKYLAR REID BOLDUC PHARMACIST

Provider Business Mailing Address
First Line	:	1620 CRABAPPLE LN
Second Line	:
City	:	CHAMPAIGN
State	:	IL
Zip	:	61822-3313
Country	:	US
Telephone Number	:	309-714-2511
Fax Number	:

Provider Business Practice Location Address
First Line	:	104 E SOUTHLINE RD
Second Line	:
City	:	TUSCOLA
State	:	IL
Zip	:	61953-2075
Country	:	US
Telephone Number	:	217-351-8497
Fax Number	:

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

Provider Enumeration Date	:	07/11/2018
Last Update Date	:	11/02/2021

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Directions to “ SKYLAR REID BOLDUC PHARMACIST” Practice Location

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