Provider Demographics
NPI:1750470969
Name:BOLTON DRUG & JEWELRY
Entity Type:Organization
Organization Name:BOLTON DRUG & JEWELRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GARY
Authorized Official - Middle Name:
Authorized Official - Last Name:BOLTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:580-933-4214
Mailing Address - Street 1:#3 N DALTON
Mailing Address - Street 2:
Mailing Address - City:VALLIANT
Mailing Address - State:OK
Mailing Address - Zip Code:74764
Mailing Address - Country:US
Mailing Address - Phone:580-933-4214
Mailing Address - Fax:580-933-7605
Practice Address - Street 1:#3 N DALTON
Practice Address - Street 2:
Practice Address - City:VALLIANT
Practice Address - State:OK
Practice Address - Zip Code:74764
Practice Address - Country:US
Practice Address - Phone:580-933-4214
Practice Address - Fax:580-933-7605
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2517563336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy