1861774200 NPI number — DR. IDA MARY JANE BOYENS PHARM.D.

Table of content: DR. IDA MARY JANE BOYENS PHARM.D. (NPI 1861774200)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1861774200 NPI number — DR. IDA MARY JANE BOYENS PHARM.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BOYENS
Provider First Name:
IDA
Provider Middle Name:
MARY JANE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PHARM.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1861774200
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/12/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2818 W 35TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ERIE
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
16506-3376
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
135 E 38TH ST
Provider Second Line Business Practice Location Address:
ATTN PHARMACY
Provider Business Practice Location Address City Name:
ERIE
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
16504-1559
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
814-860-2263
Provider Business Practice Location Address Fax Number:
814-860-2251
Provider Enumeration Date:
09/12/2011

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 183500000X , with the licence number:  RP442211 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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