Provider Demographics
NPI:1528479441
Name:BOULANGER, EDWARD A (RPH)
Entity type:Individual
Prefix:MR
First Name:EDWARD
Middle Name:A
Last Name:BOULANGER
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 1:23 ROULEAU LN
Mailing Address - Street 2:
Mailing Address - City:SHELTON
Mailing Address - State:CT
Mailing Address - Zip Code:06484-5752
Mailing Address - Country:US
Mailing Address - Phone:203-925-9189
Mailing Address - Fax:
Practice Address - Street 1:23 ROULEAU LN
Practice Address - Street 2:
Practice Address - City:SHELTON
Practice Address - State:CT
Practice Address - Zip Code:06484-5752
Practice Address - Country:US
Practice Address - Phone:203-925-9189
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-13
Last Update Date:2014-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT7789183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist