Provider Demographics
NPI:1821422445
Name:BOLUS, RYAN MATTHEW (PHARMD, BCNP)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:MATTHEW
Last Name:BOLUS
Suffix:
Gender:M
Credentials:PHARMD, BCNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 CHILDRENS PLZ
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45404-1873
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1 CHILDRENS PLZ
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45404-1873
Practice Address - Country:US
Practice Address - Phone:937-641-3351
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-30
Last Update Date:2015-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH032301031835N0905X
KY0152631835N0905X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835N0905XPharmacy Service ProvidersPharmacistNuclear