=====================================================
General NPI Number Information
=====================================================
NPI Number | 1689006918
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BOSLEY PHARMACY NO. 2 INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/09/2013
-----------------------------------------------------
Last Update Date | 08/09/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 118 S. JEFFERSON ST.
-----------------------------------------------------
City | HASTINGS
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49058
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 269-945-3429
-----------------------------------------------------
Fax | 269-945-0050
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 118 S JEFFERSON ST
-----------------------------------------------------
City | HASTINGS
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49058-1826
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 269-945-3429
-----------------------------------------------------
Fax | 269-945-0050
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHARMACIST
-----------------------------------------------------
Name | MR. MICHAEL LEN SMITH
-----------------------------------------------------
Credential | R. PH.
-----------------------------------------------------
Telephone | 269-945-3429
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 333600000X
-----------------------------------------------------
Taxonomy Name | Pharmacy
-----------------------------------------------------
License Number | 5302022795
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------