Provider Demographics
NPI:1902423882
Name:BOLBOL LLC
Entity Type:Organization
Organization Name:BOLBOL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:NAGY
Authorized Official - Middle Name:
Authorized Official - Last Name:WASSEF
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:860-875-2507
Mailing Address - Street 1:79 EAST ST
Mailing Address - Street 2:
Mailing Address - City:VERNON
Mailing Address - State:CT
Mailing Address - Zip Code:06066-3845
Mailing Address - Country:US
Mailing Address - Phone:860-875-2507
Mailing Address - Fax:860-870-8160
Practice Address - Street 1:79 EAST ST
Practice Address - Street 2:
Practice Address - City:VERNON
Practice Address - State:CT
Practice Address - Zip Code:06066-3845
Practice Address - Country:US
Practice Address - Phone:860-875-2507
Practice Address - Fax:860-870-8160
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-06-26
Last Update Date:2020-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT008071088Medicaid