Provider Demographics
NPI:1427348994
Name:BOUCHER, MICHAEL L (R PH)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:L
Last Name:BOUCHER
Suffix:
Gender:M
Credentials:R PH
Other - Prefix:
Other - First Name:MIKE
Other - Middle Name:
Other - Last Name:BOUCHER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:R PH
Mailing Address - Street 1:520 W WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:SEQUIM
Mailing Address - State:WA
Mailing Address - Zip Code:98382-3279
Mailing Address - Country:US
Mailing Address - Phone:360-681-0129
Mailing Address - Fax:360-683-1431
Practice Address - Street 1:520 W WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:SEQUIM
Practice Address - State:WA
Practice Address - Zip Code:98382-3279
Practice Address - Country:US
Practice Address - Phone:360-681-0129
Practice Address - Fax:360-683-1431
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-18
Last Update Date:2011-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH00009524183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist