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General NPI Number Information
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NPI Number | 1265195267
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Entity Type | Individual
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Provider Name | MATTHEW BRENT BULLARD PHARMD
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Gender | Male
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Dates
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Enumeration Date | 10/16/2021
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Last Update Date | 10/16/2021
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Provider Practice Location Address
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Address Line | 3515 MAIN STREET 165
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City | OLLA
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State | LA
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Zip | 71465-5613
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Country | US
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Telephone | 318-495-1100
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 302
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City | URANIA
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State | LA
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Zip | 71480-0302
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Country | US
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Telephone | 318-548-2316
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 183500000X
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Taxonomy Name | Pharmacist
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License Number | 021539
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License Number State | LA
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