Provider Demographics
NPI:1649478025
Name:BOLAND PHARMACY
Entity type:Organization
Organization Name:BOLAND PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JULIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:BOLAND
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:803-897-2133
Mailing Address - Street 1:PO BOX 50
Mailing Address - Street 2:
Mailing Address - City:ELLOREE
Mailing Address - State:SC
Mailing Address - Zip Code:29047-0050
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2732 CLEVELAND ST
Practice Address - Street 2:
Practice Address - City:ELLOREE
Practice Address - State:SC
Practice Address - Zip Code:29047
Practice Address - Country:US
Practice Address - Phone:803-897-2133
Practice Address - Fax:803-897-2752
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-06
Last Update Date:2008-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 332B00000X
SC500016933336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC716933Medicaid
4212293OtherOTHER ID NUMBER
5366260001Medicare NSC