Provider Demographics
NPI:1700472990
Name:BOLES, VICTORIA ORCHID JIN
Entity type:Individual
Prefix:
First Name:VICTORIA
Middle Name:ORCHID JIN
Last Name:BOLES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:821 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MYRTLE CREEK
Mailing Address - State:OR
Mailing Address - Zip Code:97457-9334
Mailing Address - Country:US
Mailing Address - Phone:541-863-6383
Mailing Address - Fax:
Practice Address - Street 1:821 S MAIN ST
Practice Address - Street 2:
Practice Address - City:MYRTLE CREEK
Practice Address - State:OR
Practice Address - Zip Code:97457-9334
Practice Address - Country:US
Practice Address - Phone:541-863-6383
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-12
Last Update Date:2020-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORRPH-0018158183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist