Provider Demographics
NPI:1992305783
Name:BOERIO, BRAD LEE (RPH)
Entity type:Individual
Prefix:
First Name:BRAD
Middle Name:LEE
Last Name:BOERIO
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 1:2150 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BOONVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:65233-1941
Mailing Address - Country:US
Mailing Address - Phone:660-882-6552
Mailing Address - Fax:660-882-6725
Practice Address - Street 1:2150 MAIN ST
Practice Address - Street 2:
Practice Address - City:BOONVILLE
Practice Address - State:MO
Practice Address - Zip Code:65233-1941
Practice Address - Country:US
Practice Address - Phone:660-882-6552
Practice Address - Fax:660-882-6725
Is Sole Proprietor?:No
Enumeration Date:2020-10-29
Last Update Date:2020-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO041223183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist