Provider Demographics
NPI:1477662302
Name:BOLTON, THOMAS MCLEAN (RPH)
Entity Type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:MCLEAN
Last Name:BOLTON
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 1:417 E BALTIMORE ST
Mailing Address - Street 2:UNIT A
Mailing Address - City:TANEYTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21787-2300
Mailing Address - Country:US
Mailing Address - Phone:410-756-5240
Mailing Address - Fax:
Practice Address - Street 1:417 E BALTIMORE ST
Practice Address - Street 2:UNIT A
Practice Address - City:TANEYTOWN
Practice Address - State:MD
Practice Address - Zip Code:21787-2300
Practice Address - Country:US
Practice Address - Phone:410-756-5240
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDP03001332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MPC22369OtherBOC ORTHOTIC/PROSTHET
MD12598OtherSTATE PHARMACY LIC
MDCFO02610OtherABC IN ORTHOTICS/PROSTHET