Provider Demographics
NPI:1326650664
Name:BOLT, RICHARD WAYNE III (PHARMD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:WAYNE
Last Name:BOLT
Suffix:III
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 E GRANADA BLVD
Mailing Address - Street 2:
Mailing Address - City:ORMOND BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32176-6632
Mailing Address - Country:US
Mailing Address - Phone:386-677-8849
Mailing Address - Fax:386-673-7661
Practice Address - Street 1:205 E GRANADA BLVD
Practice Address - Street 2:
Practice Address - City:ORMOND BEACH
Practice Address - State:FL
Practice Address - Zip Code:32176-6632
Practice Address - Country:US
Practice Address - Phone:386-677-8849
Practice Address - Fax:386-673-7661
Is Sole Proprietor?:No
Enumeration Date:2020-08-18
Last Update Date:2020-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS55839183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist