Amie Nicole Boulanger, RPH
Individual provider Active NPI Pharmacist · Granger, IN
NPI 1972190254 · NPPES record last updated Dec 22, 2020
Key facts
- NPI
- 1972190254
- Entity type
- Individual (NPI type 1)
- Primary specialty
- Pharmacist 183500000X
- License
- 26019763A (IN)
- Practice address
- 12850 Adams Rd
Granger, IN 46530-7183 - Phone
- (574) 807-8234
- NPI assigned
- Dec 21, 2020
- Sex
- Female
- Sole proprietor
- No
Organizations & group practices 1
Medicare participation
- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
- Medicare enrollment (NPD)
- No
- Credentials
- Registered Pharmacist
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 26019763A | IN | MD | Pharmacist |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| MSM Holdco, LLC | Current |
Accepting new patients |
Locations
12850 State Road 23
Granger, IN 46530
Phone (574) 807-8233
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Pharmacist | 183500000X | 26019763A | IN | Yes |
Addresses
Primary practice location
12850 Adams Rd
Granger, IN 46530-7183
Mailing address
65875 Turpin Rd
Cassopolis, MI 49031-9630
Phone (574) 876-7177
Electronic endpoints
| Type | Endpoint | Use | Affiliation |
|---|---|---|---|
| CONNECT URL | Granger |
Other providers in Granger, IN
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Dec 22, 2020. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.