=====================================================
General NPI Number Information
=====================================================
NPI Number | 1649547373
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ALBERT ELLWSORTH BOSWELL III RPH
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/23/2011
-----------------------------------------------------
Last Update Date | 11/23/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4201 MEADOWDALE BLVD
-----------------------------------------------------
City | NORTH CHESTERFIELD
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23234-5465
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 804-271-8100
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7714 CENTERBROOK CT
-----------------------------------------------------
City | CHESTERFIELD
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23832-9223
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 804-370-9060
-----------------------------------------------------
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 | 0202009035
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------