Provider Demographics
NPI:1689726937
Name:BOULDER CREEK PHARMACY INC
Entity Type:Organization
Organization Name:BOULDER CREEK PHARMACY INC
Other - Org Name:FELTON PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:LOCATELLI
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:831-338-2144
Mailing Address - Street 1:6240 HIGHWAY 9
Mailing Address - Street 2:
Mailing Address - City:FELTON
Mailing Address - State:CA
Mailing Address - Zip Code:95018-9713
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6240 HIGHWAY 9
Practice Address - Street 2:
Practice Address - City:FELTON
Practice Address - State:CA
Practice Address - Zip Code:95018-9713
Practice Address - Country:US
Practice Address - Phone:831-335-4461
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-17
Last Update Date:2008-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
CAPHY391453336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
0501280OtherNCPDP PROVIDER IDENTIFICATION NUMBER
CAPHA188600Medicaid