Provider Demographics
NPI:1073988697
Name:BOLIVAR, SAMANTHA MARIA (PHARMD, RPH)
Entity Type:Individual
Prefix:DR
First Name:SAMANTHA
Middle Name:MARIA
Last Name:BOLIVAR
Suffix:
Gender:F
Credentials:PHARMD, RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22 MARLBORO ST
Mailing Address - Street 2:
Mailing Address - City:DEDHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02026-1423
Mailing Address - Country:US
Mailing Address - Phone:508-821-6393
Mailing Address - Fax:
Practice Address - Street 1:22 MARLBORO ST
Practice Address - Street 2:
Practice Address - City:DEDHAM
Practice Address - State:MA
Practice Address - Zip Code:02026-1423
Practice Address - Country:US
Practice Address - Phone:508-821-6393
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-08
Last Update Date:2015-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA236117183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA236117OtherMA BOP REGISTRATION