=====================================================
General NPI Number Information
=====================================================
NPI Number | 1447566476
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | NATHAN BULLOCK PHARMD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/27/2010
-----------------------------------------------------
Last Update Date | 08/27/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1324 N STATE ST
-----------------------------------------------------
City | PROVO
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84604-2419
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 801-374-2015
-----------------------------------------------------
Fax | 801-374-9954
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 743 W MEADOW SIDE DR
-----------------------------------------------------
City | SARATOGA SPRINGS
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84045-5316
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 801-494-5092
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 6023383-1701
-----------------------------------------------------
License Number State | UT
-----------------------------------------------------