Provider Demographics
NPI:1225179542
Name:BOLTINGHOUSE CORPORATION
Entity Type:Organization
Organization Name:BOLTINGHOUSE CORPORATION
Other - Org Name:BURCH DRUG STORE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST IN CHARGE/PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:KAYE
Authorized Official - Last Name:BOLTINGHOUSE
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:570-672-2711
Mailing Address - Street 1:120 W VALLEY AVE
Mailing Address - Street 2:
Mailing Address - City:ELYSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17824-9703
Mailing Address - Country:US
Mailing Address - Phone:570-672-2711
Mailing Address - Fax:570-672-1311
Practice Address - Street 1:120 W VALLEY AVE
Practice Address - Street 2:
Practice Address - City:ELYSBURG
Practice Address - State:PA
Practice Address - Zip Code:17824-9703
Practice Address - Country:US
Practice Address - Phone:570-672-2711
Practice Address - Fax:570-672-1311
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-09
Last Update Date:2011-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPP410295L333600000X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA241025591500001Medicaid
3917246OtherNCPDP NUMBER
PARPI002230OtherAUTHORIZATION TO ADMINISTER INJECTABLES
PARPI002230OtherAUTHORIZATION TO ADMINISTER INJECTABLES