Healthcare Provider Details

I. General information

NPI: 1194833822
Provider Name (Legal Business Name): BUNNELL PHARMACY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/25/2006
Last Update Date: 09/13/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

706 E MOODY BLVD
BUNNELL FL
32110-0895
US

IV. Provider business mailing address

PO BOX 895
BUNNELL FL
32110-0895
US

V. Phone/Fax

Practice location:
  • Phone: 386-437-3325
  • Fax: 386-437-1533
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberPH0008958
License Number StateFL

VIII. Authorized Official

Name: JOSEPH CORGAN
Title or Position: OWNER
Credential: RPH
Phone: 386-437-3325