Healthcare Provider Details

I. General information

NPI: 1154351039
Provider Name (Legal Business Name): BRUCE DANIEL BILODEAU B.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/04/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 FOOTHILL BLVD
SALT LAKE CITY UT
84148
US

IV. Provider business mailing address

2164 EAST NEW HORIZON DR .
SANDY UT
84093
US

V. Phone/Fax

Practice location:
  • Phone: 801-582-1565
  • Fax:
Mailing address:
  • Phone: 801-582-1565
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P1200X
TaxonomyPharmacotherapy Pharmacist
License Number152007-1701
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: