=====================================================
General NPI Number Information
=====================================================
NPI Number | 1568345916
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CODY BOLAND PHARMD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/30/2025
-----------------------------------------------------
Last Update Date | 08/04/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 820 HIGHWAY 19 N STE 195
-----------------------------------------------------
City | MERIDIAN
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39307-5820
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 719-448-2601
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 128 CRESCENT LAKE RD
-----------------------------------------------------
City | MERIDIAN
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39301-9119
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 662-263-6482
-----------------------------------------------------
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 | E-102053
-----------------------------------------------------
License Number State | MS
-----------------------------------------------------