Provider Demographics
NPI:1669854931
Name:BOLANDER, NATHAN
Entity Type:Individual
Prefix:
First Name:NATHAN
Middle Name:
Last Name:BOLANDER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:570 S STATE ST
Mailing Address - Street 2:
Mailing Address - City:SHELLEY
Mailing Address - State:ID
Mailing Address - Zip Code:83274-1470
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:570 S STATE ST
Practice Address - Street 2:
Practice Address - City:SHELLEY
Practice Address - State:ID
Practice Address - Zip Code:83274-1470
Practice Address - Country:US
Practice Address - Phone:208-357-0473
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-23
Last Update Date:2016-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP7270183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist