Provider Demographics
NPI:1013072206
Name:BOLAND PHARMACY 2
Entity Type:Organization
Organization Name:BOLAND PHARMACY 2
Other - Org Name:BOLAND PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARM
Authorized Official - Prefix:
Authorized Official - First Name:JUDITH
Authorized Official - Middle Name:
Authorized Official - Last Name:RICKENBACKER
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:843-462-7646
Mailing Address - Street 1:PO BOX 96
Mailing Address - Street 2:
Mailing Address - City:HARLEYVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29448-0096
Mailing Address - Country:US
Mailing Address - Phone:843-462-7646
Mailing Address - Fax:
Practice Address - Street 1:108 W MAIN ST
Practice Address - Street 2:
Practice Address - City:HARLEYVILLE
Practice Address - State:SC
Practice Address - Zip Code:29448
Practice Address - Country:US
Practice Address - Phone:843-462-7646
Practice Address - Fax:843-462-7646
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-27
Last Update Date:2017-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
SC4283336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCSC704285Medicaid
2087926OtherPK