Provider Demographics
NPI:1629165584
Name:BOULDER CREEK PHARMACY
Entity Type:Organization
Organization Name:BOULDER CREEK PHARMACY
Other - Org Name:A CALIF CORP
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:E
Authorized Official - Last Name:LOCATELLI
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:831-338-2241
Mailing Address - Street 1:PO BOX 910
Mailing Address - Street 2:
Mailing Address - City:BOULDER CREEK
Mailing Address - State:CA
Mailing Address - Zip Code:95006
Mailing Address - Country:US
Mailing Address - Phone:831-338-2144
Mailing Address - Fax:831-338-0901
Practice Address - Street 1:13081 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:BOULDER CREEK
Practice Address - State:CA
Practice Address - Zip Code:95006
Practice Address - Country:US
Practice Address - Phone:831-338-2144
Practice Address - Fax:831-338-0901
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPHY30621333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
0521650OtherNABP #
CAPHA306210Medicaid