Provider Demographics
NPI:1215276902
Name:BOUCHARD, MATTHEW WILLIAM (BS)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:WILLIAM
Last Name:BOUCHARD
Suffix:
Gender:M
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6380 POLARIS AVE UNIT B
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89118-3821
Mailing Address - Country:US
Mailing Address - Phone:702-269-2005
Mailing Address - Fax:702-269-4428
Practice Address - Street 1:6380 POLARIS AVE UNIT B
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89118-3821
Practice Address - Country:US
Practice Address - Phone:702-269-2005
Practice Address - Fax:702-269-4428
Is Sole Proprietor?:No
Enumeration Date:2013-01-31
Last Update Date:2014-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV16706183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY016497OtherPHARMACIST LICENSE
MSP11976OtherPHARMACIST LICENSE
ARPD11738OtherPHARMACIST LICENSE
NV16706OtherPHARMACIST LICENSE
AZS019524OtherPHARMACIST LICENSE
TN36982OtherPHARMACIST LICENSE
ORRPH-0012926OtherPHARMACIST LICENSE
NE14059OtherPHARMACIST LICENSE
VA202011979OtherPHARMACIST LICENSE
LAPST.019679OtherPHARMACIST LICENSE
MD20910OtherPHARMACIST LICENSE