Provider Demographics
NPI:1861002776
Name:BOLLER, MICHAEL
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:BOLLER
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 1:2115 GRAND BLVD
Mailing Address - Street 2:
Mailing Address - City:CEDAR FALLS
Mailing Address - State:IA
Mailing Address - Zip Code:50613-4760
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5100 PRAIRIE PKWY STE 106
Practice Address - Street 2:
Practice Address - City:CEDAR FALLS
Practice Address - State:IA
Practice Address - Zip Code:50613-8155
Practice Address - Country:US
Practice Address - Phone:319-222-2906
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-05
Last Update Date:2020-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA23859183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist