=====================================================
General NPI Number Information
=====================================================
NPI Number | 1598950453
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARILYN NOVELL BULLOCH PHARMD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/12/2007
-----------------------------------------------------
Last Update Date | 07/11/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | UNIVERSITY MEDICAL CTR BOX 870326
-----------------------------------------------------
City | TUSCALOOSA
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 35487-0001
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 276-732-2353
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1605 KATHY LN
-----------------------------------------------------
City | FULTONDALE
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 35068-1464
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 276-732-2353
-----------------------------------------------------
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 | 15543
-----------------------------------------------------
License Number State | AL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 0202207988
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | RP00007154
-----------------------------------------------------
License Number State | WV
-----------------------------------------------------