Healthcare Provider Details

I. General information

NPI: 1831860006
Provider Name (Legal Business Name): RALYN DANIELS BULLOCK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/27/2021
Last Update Date: 05/20/2026
Certification Date: 05/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1685 OLD PENDERGRASS RD
JEFFERSON GA
30549-2705
US

IV. Provider business mailing address

306 KATHERINE DR
JEFFERSON GA
30549-2107
US

V. Phone/Fax

Practice location:
  • Phone: 706-387-7620
  • Fax:
Mailing address:
  • Phone: 404-310-5590
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License NumberRPH033179
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: