Healthcare Provider Details

I. General information

NPI: 1649478025
Provider Name (Legal Business Name): BOLAND PHARMACY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/06/2007
Last Update Date: 09/23/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2732 CLEVELAND ST
ELLOREE SC
29047
US

IV. Provider business mailing address

PO BOX 50
ELLOREE SC
29047-0050
US

V. Phone/Fax

Practice location:
  • Phone: 803-897-2133
  • Fax: 803-897-2752
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number50001693
License Number StateSC

VIII. Authorized Official

Name: JULIAN BOLAND
Title or Position: OWNER
Credential:
Phone: 803-897-2133