Healthcare Provider Details

I. General information

NPI: 1063581304
Provider Name (Legal Business Name): RANDY B BOLAND
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/08/2006
Last Update Date: 03/20/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7107 CHARLSTON HWY
BOWMAN SC
29018-0398
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 TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number2899
License Number StateSC

VIII. Authorized Official

Name: CAROLYN BOLAND
Title or Position: RPH
Credential: RPH
Phone: 803-829-2547