MEDICARE: MR. ERNEST WILMOTH BRISTOL JR. ERNEST BRISTOL

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	13963	AZ

General Provider Information

NPI Number	:	1063728640
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. ERNEST WILMOTH BRISTOL JR. ERNEST BRISTOL

Provider Business Mailing Address
First Line	:	2360 HWY 95
Second Line	:
City	:	BULLHEAD CITY
State	:	AZ
Zip	:	86442-7303
Country	:	US
Telephone Number	:	928-763-5858
Fax Number	:	928-763-0972

Provider Business Practice Location Address
First Line	:	2360 HIWAY 95
Second Line	:
City	:	BULLHEAD CITY
State	:	AZ
Zip	:	86442-7303
Country	:	US
Telephone Number	:	928-763-5858
Fax Number	:	928-763-0972

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/20/2010
Last Update Date	:	08/20/2010

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