Provider Demographics
NPI:1386941169
Name:BOURDEAU, WILLIAM ROBERT (RPH)
Entity type:Individual
Prefix:MR
First Name:WILLIAM
Middle Name:ROBERT
Last Name:BOURDEAU
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:455 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SOUTHBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:01550-3760
Mailing Address - Country:US
Mailing Address - Phone:508-765-5922
Mailing Address - Fax:508-765-2726
Practice Address - Street 1:455 MAIN ST
Practice Address - Street 2:
Practice Address - City:SOUTHBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:01550-3760
Practice Address - Country:US
Practice Address - Phone:508-765-5922
Practice Address - Fax:508-765-2726
Is Sole Proprietor?:No
Enumeration Date:2011-02-14
Last Update Date:2011-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA19856183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist