MEDICARE: NATHAN DONOVAN BOYLSTON JR.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	3509	SC

General Provider Information

NPI Number	:	1881991123
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NATHAN DONOVAN BOYLSTON JR.

Provider Business Mailing Address
First Line	:	1532 LAKE MURRAY BLVD
Second Line	:
City	:	COLUMBIA
State	:	SC
Zip	:	29212-8622
Country	:	US
Telephone Number	:	803-732-1975
Fax Number	:

Provider Business Practice Location Address
First Line	:	1532 LAKE MURRAY BLVD
Second Line	:
City	:	COLUMBIA
State	:	SC
Zip	:	29212-8622
Country	:	US
Telephone Number	:	803-732-1975
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/23/2011
Last Update Date	:	02/23/2011

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