Provider Demographics
NPI:1235518432
Name:BULLARD, HALEY
Entity Type:Individual
Prefix:
First Name:HALEY
Middle Name:
Last Name:BULLARD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1520 OHIO AVE S
Mailing Address - Street 2:
Mailing Address - City:LIVE OAK
Mailing Address - State:FL
Mailing Address - Zip Code:32064-4514
Mailing Address - Country:US
Mailing Address - Phone:386-362-2591
Mailing Address - Fax:
Practice Address - Street 1:1520 OHIO AVE S
Practice Address - Street 2:
Practice Address - City:LIVE OAK
Practice Address - State:FL
Practice Address - Zip Code:32064-4514
Practice Address - Country:US
Practice Address - Phone:386-362-2591
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-05-21
Last Update Date:2015-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS50927183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist