Healthcare Provider Details

I. General information

NPI: 1104195510
Provider Name (Legal Business Name): MIDHASSO BULLI FOGE PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/14/2011
Last Update Date: 12/14/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22721 WOODFORD TEHACHAPI RD
TEHACHAPI CA
93561-7938
US

IV. Provider business mailing address

22721 WOODFORD TEHACHAPI RD
TEHACHAPI CA
93561-7938
US

V. Phone/Fax

Practice location:
  • Phone: 763-439-6526
  • Fax:
Mailing address:
  • Phone: 763-439-6526
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number66228
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: