Healthcare Provider Details

I. General information

NPI: 1528992377
Provider Name (Legal Business Name): BOSCOVS DEPARTMENT STORE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/09/2026
Last Update Date: 06/09/2026
Certification Date: 06/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2310 N SALISBURY BLVD
SALISBURY MD
21801-7380
US

IV. Provider business mailing address

4500 PERKIOMEN AVE
READING PA
19606-3946
US

V. Phone/Fax

Practice location:
  • Phone: 410-548-2163
  • Fax:
Mailing address:
  • Phone: 610-779-2000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number
License Number State

VIII. Authorized Official

Name: MICHAEL DERENZO
Title or Position: DIRECTOR OF OPTICAL SERVICES
Credential:
Phone: 856-759-9905