Provider Demographics
NPI:1689499410
Name:BOUGHMAN, WADE LEWIS (RPH)
Entity type:Individual
Prefix:
First Name:WADE
Middle Name:LEWIS
Last Name:BOUGHMAN
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 1:4750 E 450 S STE A
Mailing Address - Street 2:
Mailing Address - City:WHITESTOWN
Mailing Address - State:IN
Mailing Address - Zip Code:46075-8404
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4750 E 450 S STE A
Practice Address - Street 2:
Practice Address - City:WHITESTOWN
Practice Address - State:IN
Practice Address - Zip Code:46075-8404
Practice Address - Country:US
Practice Address - Phone:765-748-8248
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-18
Last Update Date:2024-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26019553A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist