Provider Demographics
NPI:1225465453
Name:BULTI, MULUGETA TEKA
Entity Type:Individual
Prefix:
First Name:MULUGETA
Middle Name:TEKA
Last Name:BULTI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:424 LEGACY DR.
Mailing Address - Street 2:
Mailing Address - City:BRUNSWICK
Mailing Address - State:GA
Mailing Address - Zip Code:31525
Mailing Address - Country:US
Mailing Address - Phone:561-329-9861
Mailing Address - Fax:
Practice Address - Street 1:3487 CYPRESS MILL RD
Practice Address - Street 2:
Practice Address - City:BRUNSWICK
Practice Address - State:GA
Practice Address - Zip Code:31520-2857
Practice Address - Country:US
Practice Address - Phone:912-265-6330
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-10-02
Last Update Date:2013-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX52735183500000X
GARPH027102183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist