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General NPI Number Information
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NPI Number | 1114735818
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Entity Type | Individual
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Provider Name | MATTHEW BOLEN
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Gender | Male
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Dates
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Enumeration Date | 12/27/2024
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Last Update Date | 12/27/2024
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Provider Practice Location Address
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Address Line | 145 S PLUMMER RD
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City | STAR
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State | ID
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Zip | 83669-6199
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Country | US
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Telephone | 208-286-0906
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Fax |
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Provider Business Mailing Address
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Address Line | 11714 W SILVER CITY ST
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City | BOISE
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State | ID
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Zip | 83713-7859
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Country | US
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Telephone | 208-473-8835
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 183500000X
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Taxonomy Name | Pharmacist
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License Number | P11047
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License Number State | ID
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