Basic Information
| Provider Information | |||||||||
| NPI: | 1740885615 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BOELKE | ||||||||
| FirstName: | TARA | ||||||||
| MiddleName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 207 S LEBANON ST | ||||||||
| Address2: | |||||||||
| City: | LEBANON | ||||||||
| State: | IN | ||||||||
| PostalCode: | 460522544 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7654823630 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 207 S LEBANON ST | ||||||||
| Address2: | |||||||||
| City: | LEBANON | ||||||||
| State: | IN | ||||||||
| PostalCode: | 460522544 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7654823630 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/01/2020 | ||||||||
| LastUpdateDate: | 12/01/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/01/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 183500000X | 26028102A | IN | Y | Pharmacy Service Providers | Pharmacist |
No ID Information.