Provider Demographics
NPI:1730198664
Name:BOYLAN, THEODORE J (PHARMD)
Entity type:Individual
Prefix:MR
First Name:THEODORE
Middle Name:J
Last Name:BOYLAN
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1741 N WARREN AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53202
Mailing Address - Country:US
Mailing Address - Phone:312-479-2656
Mailing Address - Fax:
Practice Address - Street 1:9051 W HEATHER AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53224
Practice Address - Country:US
Practice Address - Phone:414-410-8101
Practice Address - Fax:414-410-8181
Is Sole Proprietor?:No
Enumeration Date:2006-08-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI13961040183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist