Healthcare Provider Details

I. General information

NPI: 1629152087
Provider Name (Legal Business Name): MR. RANDY B BOLAND
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/24/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7107 CHARLESTON HWY
BOWMAN SC
29018
US

IV. Provider business mailing address

PO BOX 398
BOWMAN SC
29018-0398
US

V. Phone/Fax

Practice location:
  • Phone: 803-829-2547
  • Fax: 803-829-2548
Mailing address:
  • Phone: 803-829-2547
  • Fax: 803-829-2548

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License Number10120
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: