Provider Demographics
NPI:1780639633
Name:JOHN M BOVE
Entity type:Organization
Organization Name:JOHN M BOVE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:PATRICIA
Authorized Official - Middle Name:M
Authorized Official - Last Name:ABATIELL-BOVE
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:802-773-3888
Mailing Address - Street 1:PO BOX 1852
Mailing Address - Street 2:STATION A, GERICARE
Mailing Address - City:RUTLAND
Mailing Address - State:VT
Mailing Address - Zip Code:05701-1852
Mailing Address - Country:US
Mailing Address - Phone:802-773-3888
Mailing Address - Fax:802-775-7400
Practice Address - Street 1:17 MENDON VIEW DRIVE
Practice Address - Street 2:GERICARE
Practice Address - City:MENDON
Practice Address - State:VT
Practice Address - Zip Code:05701
Practice Address - Country:US
Practice Address - Phone:802-773-3888
Practice Address - Fax:802-775-7400
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-22
Last Update Date:2023-03-07
Deactivation Date:2008-06-10
Deactivation Code:
Reactivation Date:2008-08-04
Provider Licenses
StateLicense IDTaxonomies
VT038-0003319332B00000X, 3336C0003X, 333600000X
VT03800033193336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
47-03799OtherNCPDP NUMBER
VT038-0003319OtherPHARMACY LIC
4703799OtherNCPDP
VT038-0003319OtherPHARMACY LICENSE
VT1007643Medicaid
BG7104413OtherDEA LICENSE
VT1007643Medicaid
4014900001Medicare NSC
VT038-0003319OtherPHARMACY LICENSE