1629076385 NPI number — DR. WALLENE Z BULLARD PHARMD, BCPS

Table of content: DR. WALLENE Z BULLARD PHARMD, BCPS (NPI 1629076385)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629076385 NPI number — DR. WALLENE Z BULLARD PHARMD, BCPS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BULLARD
Provider First Name:
WALLENE
Provider Middle Name:
Z
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PHARMD, BCPS
Provider Gender Code:
F

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:
1629076385
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/28/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 953
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RANDALLSTOWN
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21133-0953
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
202-427-3010
Provider Business Mailing Address Fax Number:
202-563-3909

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
750 1ST ST NE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WASHINGTON
Provider Business Practice Location Address State Name:
DC
Provider Business Practice Location Address Postal Code:
20002-4241
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
202-427-3010
Provider Business Practice Location Address Fax Number:
202-563-3909
Provider Enumeration Date:
07/07/2005

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: 1835P1200X , with the licence number:  16065 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1835P1200X , with the licence number: 12574 , registered in the state of NV ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1835P1200X , with the licence number: 47645 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1835P1200X , with the licence number: PH100000175 , registered in the state of DC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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