Provider Demographics
NPI:1265925606
Name:BOUNTIFUL PHARMACY LLC
Entity type:Organization
Organization Name:BOUNTIFUL PHARMACY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:
Authorized Official - Last Name:CHRISTENSEN
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:775-463-2345
Mailing Address - Street 1:PO BOX 823
Mailing Address - Street 2:
Mailing Address - City:YERINGTON
Mailing Address - State:NV
Mailing Address - Zip Code:89447-0823
Mailing Address - Country:US
Mailing Address - Phone:775-463-2345
Mailing Address - Fax:
Practice Address - Street 1:1250 NEVADA AVE # 2
Practice Address - Street 2:
Practice Address - City:SILVER SPRINGS
Practice Address - State:NV
Practice Address - Zip Code:89429-7979
Practice Address - Country:US
Practice Address - Phone:775-909-4855
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-06-11
Last Update Date:2020-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVPH034673336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy