Healthcare Provider Details

I. General information

NPI: 1699760298
Provider Name (Legal Business Name): BOLTONS PHARMACY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/20/2005
Last Update Date: 07/10/2023
Certification Date: 07/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

128 W MAIN ST
WATERTOWN NY
13601-1989
US

IV. Provider business mailing address

128 W MAIN ST
WATERTOWN NY
13601-1989
US

V. Phone/Fax

Practice location:
  • Phone: 315-782-5961
  • Fax: 315-782-4496
Mailing address:
  • Phone: 315-782-5961
  • Fax: 315-782-4496

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number015555
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number015555
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number015555
License Number StateNY

VIII. Authorized Official

Name: DR. COLLEEN SIGNOR
Title or Position: REGISTERED PHAMACIST
Credential: RPH
Phone: 315-782-5961