Provider Demographics
NPI:1780781070
Name:BOLTON PHARMACY INC
Entity type:Organization
Organization Name:BOLTON PHARMACY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KARL
Authorized Official - Middle Name:
Authorized Official - Last Name:LINK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:860-643-0165
Mailing Address - Street 1:PO BOX 9216
Mailing Address - Street 2:
Mailing Address - City:BOLTON
Mailing Address - State:CT
Mailing Address - Zip Code:06043-9216
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:667 BOSTON TPKE
Practice Address - Street 2:
Practice Address - City:BOLTON
Practice Address - State:CT
Practice Address - Zip Code:06043-7401
Practice Address - Country:US
Practice Address - Phone:860-643-0165
Practice Address - Fax:860-649-3783
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2010-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
CTPCY009113336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
0702882OtherNCPDP PROVIDER IDENTIFICATION NUMBER
CT004031043Medicaid
0702882OtherNCPDP PROVIDER IDENTIFICATION NUMBER