Provider Demographics
NPI:1306912159
Name:BOUCHE, ROBERT
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:
Last Name:BOUCHE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1111 PARTRIDGE RUN
Mailing Address - Street 2:
Mailing Address - City:SHEBOYGAN FALLS
Mailing Address - State:WI
Mailing Address - Zip Code:53085-1846
Mailing Address - Country:US
Mailing Address - Phone:920-467-4046
Mailing Address - Fax:
Practice Address - Street 1:3529 SUPERIOR AVE
Practice Address - Street 2:
Practice Address - City:SHEBOYGAN
Practice Address - State:WI
Practice Address - Zip Code:53081-1865
Practice Address - Country:US
Practice Address - Phone:920-459-2755
Practice Address - Fax:920-803-7519
Is Sole Proprietor?:No
Enumeration Date:2006-11-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI9741-042183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist