Provider Demographics
NPI:1477638567
Name:BOULEVARD PHARMACY INC
Entity Type:Organization
Organization Name:BOULEVARD PHARMACY INC
Other - Org Name:BOULEVARD PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JACEY
Authorized Official - Middle Name:
Authorized Official - Last Name:COLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:918-336-2140
Mailing Address - Street 1:1117 SE FRANK PHILLIPS BLVD
Mailing Address - Street 2:
Mailing Address - City:BARTLESVILLE
Mailing Address - State:OK
Mailing Address - Zip Code:74003-4319
Mailing Address - Country:US
Mailing Address - Phone:918-336-2140
Mailing Address - Fax:918-336-2145
Practice Address - Street 1:1117 SE FRANK PHILLIPS BLVD
Practice Address - Street 2:
Practice Address - City:BARTLESVILLE
Practice Address - State:OK
Practice Address - Zip Code:74003-4319
Practice Address - Country:US
Practice Address - Phone:918-336-2140
Practice Address - Fax:918-336-2145
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-26
Last Update Date:2021-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
3703801OtherNCPDP PROVIDER IDENTIFICATION NUMBER
OK100232160AMedicaid
3703801OtherNCPDP PROVIDER IDENTIFICATION NUMBER