Healthcare Provider Details

I. General information

NPI: 1629165584
Provider Name (Legal Business Name): BOULDER CREEK PHARMACY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/10/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13081 CENTRAL AVE
BOULDER CREEK CA
95006
US

IV. Provider business mailing address

PO BOX 910
BOULDER CREEK CA
95006
US

V. Phone/Fax

Practice location:
  • Phone: 831-338-2144
  • Fax: 831-338-0901
Mailing address:
  • Phone: 831-338-2144
  • Fax: 831-338-0901

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License NumberPHY30621
License Number StateCA

VIII. Authorized Official

Name: MR. ROBERT E LOCATELLI
Title or Position: PRESIDENT
Credential: RPH
Phone: 831-338-2241