=====================================================
General NPI Number Information
=====================================================
NPI Number | 1538659636
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BRUCE FREDERICK BOELTER R.PH.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/14/2018
-----------------------------------------------------
Last Update Date | 05/14/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 450 E ROMIE LN
-----------------------------------------------------
City | SALINAS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93901-4029
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 831-759-2637
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 225 CROSSROADS BOULEVARD PMB 331
-----------------------------------------------------
City | CARMEL
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93923
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-893-4899
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 9874-040
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | S007212
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 59699
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | PS55787
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #5
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 44096
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------