Provider Demographics
NPI:1518927649
Name:BOLGER PHARMACY INC
Entity Type:Organization
Organization Name:BOLGER PHARMACY INC
Other - Org Name:HI-SCHOOL PHARMACY #1152
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JACK
Authorized Official - Middle Name:
Authorized Official - Last Name:HOLT
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:503-873-8391
Mailing Address - Street 1:916 W EVERGREEN BLVD
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98660-3035
Mailing Address - Country:US
Mailing Address - Phone:360-213-2236
Mailing Address - Fax:360-213-2238
Practice Address - Street 1:207 S BROADWAY
Practice Address - Street 2:
Practice Address - City:ESTACADA
Practice Address - State:OR
Practice Address - Zip Code:97023
Practice Address - Country:US
Practice Address - Phone:503-630-3266
Practice Address - Fax:503-630-3288
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-24
Last Update Date:2010-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORNPA0006369333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
3810961OtherNCPDP
OK049747Medicaid
OK049747Medicaid