Provider Demographics
NPI:1184736134
Name:BOATNERWERKS
Entity type:Organization
Organization Name:BOATNERWERKS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:LEWIS
Authorized Official - Last Name:BOATNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:334-264-1110
Mailing Address - Street 1:PO BOX 70369
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36107-0369
Mailing Address - Country:US
Mailing Address - Phone:334-264-1110
Mailing Address - Fax:334-264-1062
Practice Address - Street 1:1751 UPPER WETUMPKA ROAD
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:AL
Practice Address - Zip Code:36107
Practice Address - Country:US
Practice Address - Phone:334-264-1110
Practice Address - Fax:334-264-1062
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2008-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL199333336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL100002719Medicaid
AL0126056OtherNABP / NCPDP