Healthcare Provider Details

I. General information

NPI: 1215441605
Provider Name (Legal Business Name): JAY BOYLL
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/22/2017
Last Update Date: 12/17/2022
Certification Date: 12/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

535 E BROADWAY
COUNCIL BLUFFS IA
51503-4419
US

IV. Provider business mailing address

16913 AURORA ST
OMAHA NE
68136-1634
US

V. Phone/Fax

Practice location:
  • Phone: 712-329-0930
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number12010
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: