Healthcare Provider Details

I. General information

NPI: 1689726937
Provider Name (Legal Business Name): BOULDER CREEK PHARMACY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/17/2007
Last Update Date: 12/02/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6240 HIGHWAY 9
FELTON CA
95018-9713
US

IV. Provider business mailing address

6240 HIGHWAY 9
FELTON CA
95018-9713
US

V. Phone/Fax

Practice location:
  • Phone: 831-335-4461
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberPHY39145
License Number StateCA

VIII. Authorized Official

Name: ROBERT LOCATELLI
Title or Position: OWNER
Credential: RPH
Phone: 831-338-2144