Provider Demographics
NPI:1205979002
Name:BOLIVAR GENERAL HOSPITAL PHARMACY
Entity type:Organization
Organization Name:BOLIVAR GENERAL HOSPITAL PHARMACY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMACY DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:LAURIE
Authorized Official - Middle Name:YOUNG
Authorized Official - Last Name:CRAFT
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:731-659-0251
Mailing Address - Street 1:650 NUCKOLLS RD
Mailing Address - Street 2:PO BOX 509
Mailing Address - City:BOLIVAR
Mailing Address - State:TN
Mailing Address - Zip Code:38008-1532
Mailing Address - Country:US
Mailing Address - Phone:731-658-3100
Mailing Address - Fax:731-659-0289
Practice Address - Street 1:650 NUCKOLLS RD
Practice Address - Street 2:
Practice Address - City:BOLIVAR
Practice Address - State:TN
Practice Address - Zip Code:38008-1532
Practice Address - Country:US
Practice Address - Phone:731-658-3100
Practice Address - Fax:731-659-0289
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN14023336I0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336I0012XSuppliersPharmacyInstitutional Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1402OtherSTATE PHARMACY LICENSE