Provider Demographics
NPI:1083032353
Name:BOUDETTE, JEFFREY (RPH)
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:
Last Name:BOUDETTE
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 1:1515 OHIO AVE S
Mailing Address - Street 2:
Mailing Address - City:LIVE OAK
Mailing Address - State:FL
Mailing Address - Zip Code:32064-4513
Mailing Address - Country:US
Mailing Address - Phone:386-330-2766
Mailing Address - Fax:
Practice Address - Street 1:1515 OHIO AVE S
Practice Address - Street 2:
Practice Address - City:LIVE OAK
Practice Address - State:FL
Practice Address - Zip Code:32064-4513
Practice Address - Country:US
Practice Address - Phone:386-330-2766
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-04-02
Last Update Date:2025-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS37931183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist