Provider Demographics
NPI:1699136523
Name:BOULANGER, DANIEL (RPH)
Entity type:Individual
Prefix:
First Name:DANIEL
Middle Name:
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 1:7 DURANT AVE
Mailing Address - Street 2:
Mailing Address - City:BETHEL
Mailing Address - State:CT
Mailing Address - Zip Code:06801-1906
Mailing Address - Country:US
Mailing Address - Phone:203-794-9500
Mailing Address - Fax:203-794-1005
Practice Address - Street 1:7 DURANT AVE
Practice Address - Street 2:
Practice Address - City:BETHEL
Practice Address - State:CT
Practice Address - Zip Code:06801-1906
Practice Address - Country:US
Practice Address - Phone:203-794-9500
Practice Address - Fax:203-794-1005
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-20
Last Update Date:2016-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTPCT.0004944183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist