Provider Demographics
NPI:1770243248
Name:BOLTON, JEFFERY WADE (RPH)
Entity Type:Individual
Prefix:
First Name:JEFFERY
Middle Name:WADE
Last Name:BOLTON
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2373 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:PLAINFIELD
Mailing Address - State:IN
Mailing Address - Zip Code:46168-2717
Mailing Address - Country:US
Mailing Address - Phone:317-839-3881
Mailing Address - Fax:317-839-4438
Practice Address - Street 1:2373 E MAIN ST
Practice Address - Street 2:
Practice Address - City:PLAINFIELD
Practice Address - State:IN
Practice Address - Zip Code:46168-2717
Practice Address - Country:US
Practice Address - Phone:317-839-3881
Practice Address - Fax:317-839-4438
Is Sole Proprietor?:No
Enumeration Date:2021-12-27
Last Update Date:2021-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26017902A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist