Provider Demographics
NPI:1003102914
Name:BULLARD, MALENA (PHARM D)
Entity Type:Individual
Prefix:
First Name:MALENA
Middle Name:
Last Name:BULLARD
Suffix:
Gender:F
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2650 DAKOTA DR
Mailing Address - Street 2:
Mailing Address - City:DELAND
Mailing Address - State:FL
Mailing Address - Zip Code:32724-9636
Mailing Address - Country:US
Mailing Address - Phone:310-634-5362
Mailing Address - Fax:
Practice Address - Street 1:1205 S WOODLAND BLVD STE 5
Practice Address - Street 2:
Practice Address - City:DELAND
Practice Address - State:FL
Practice Address - Zip Code:32720
Practice Address - Country:US
Practice Address - Phone:386-888-4912
Practice Address - Fax:386-269-9950
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-20
Last Update Date:2018-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS32524183500000X
CARPH50132183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist