Provider Demographics
NPI:1346332061
Name:BULLS GAP PHARMACY LLC
Entity Type:Organization
Organization Name:BULLS GAP PHARMACY LLC
Other - Org Name:BULLS GAP DRUGS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JAMA
Authorized Official - Middle Name:
Authorized Official - Last Name:BOS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:423-235-4600
Mailing Address - Street 1:412 HIGHWAY 11 E
Mailing Address - Street 2:
Mailing Address - City:BULLS GAP
Mailing Address - State:TN
Mailing Address - Zip Code:37711-3428
Mailing Address - Country:US
Mailing Address - Phone:423-235-4600
Mailing Address - Fax:423-235-5755
Practice Address - Street 1:412 HIGHWAY 11 E
Practice Address - Street 2:
Practice Address - City:BULLS GAP
Practice Address - State:TN
Practice Address - Zip Code:37711-3428
Practice Address - Country:US
Practice Address - Phone:423-235-4600
Practice Address - Fax:423-235-5755
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-29
Last Update Date:2017-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
TN39643336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4437023Medicaid
2137146OtherPK
5058020001Medicare NSC