Provider Demographics
NPI:1376623629
Name:BOSTICK, ALVA DANIEL HOWARD (RPH)
Entity Type:Individual
Prefix:MR
First Name:ALVA
Middle Name:DANIEL HOWARD
Last Name:BOSTICK
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:549 S WEST ST
Mailing Address - Street 2:PO BOX 686
Mailing Address - City:PIKETON
Mailing Address - State:OH
Mailing Address - Zip Code:45661-0686
Mailing Address - Country:US
Mailing Address - Phone:740-289-2269
Mailing Address - Fax:740-289-4586
Practice Address - Street 1:549 S WEST ST
Practice Address - Street 2:
Practice Address - City:PIKETON
Practice Address - State:OH
Practice Address - Zip Code:45661-0686
Practice Address - Country:US
Practice Address - Phone:740-289-2269
Practice Address - Fax:740-289-4586
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03310471183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0387531Medicaid
OH0387531Medicaid