Provider Demographics
NPI:1538592621
Name:BOLTON, SPENCER WAYNE
Entity type:Individual
Prefix:DR
First Name:SPENCER
Middle Name:WAYNE
Last Name:BOLTON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1800 KILLIAN LAKES DR
Mailing Address - Street 2:APT 4101
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29203-8804
Mailing Address - Country:US
Mailing Address - Phone:606-215-5788
Mailing Address - Fax:
Practice Address - Street 1:2224 AUGUSTA RD
Practice Address - Street 2:
Practice Address - City:WEST COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29169-4524
Practice Address - Country:US
Practice Address - Phone:803-791-3676
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-13
Last Update Date:2013-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC14297183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist