Healthcare Provider Details

I. General information

NPI: 1871697383
Provider Name (Legal Business Name): SUZANNE M. BULLARD R.PH.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/13/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3019 COIT AVE NE
GRAND RAPIDS MI
49505-3376
US

IV. Provider business mailing address

13458 REDBIRD LN
GRAND HAVEN MI
49417-9464
US

V. Phone/Fax

Practice location:
  • Phone: 616-365-9575
  • Fax: 616-365-9487
Mailing address:
  • Phone: 616-847-9917
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number5302028597
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: