1619384435 NPI number — MR. RUSTON GEORGE BOLAND R.PH.

Table of content: MR. RUSTON GEORGE BOLAND R.PH. (NPI 1619384435)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619384435 NPI number — MR. RUSTON GEORGE BOLAND R.PH.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BOLAND
Provider First Name:
RUSTON
Provider Middle Name:
GEORGE
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
R.PH.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1619384435
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/14/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 528
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ELLOREE
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29047
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
803-897-2303
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
402 E MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MONCKS CORNER
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29461
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
843-761-5255
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/14/2014

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 183500000X , with the licence number:  5423 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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