Provider Demographics
NPI:1417541574
Name:BULLOCK, BRYAN RICHARD (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:BRYAN
Middle Name:RICHARD
Last Name:BULLOCK
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1067 KILKORMIC ST
Mailing Address - Street 2:
Mailing Address - City:TOMS RIVER
Mailing Address - State:NJ
Mailing Address - Zip Code:08753-3148
Mailing Address - Country:US
Mailing Address - Phone:732-703-8448
Mailing Address - Fax:
Practice Address - Street 1:811 FISCHER BLVD
Practice Address - Street 2:
Practice Address - City:TOMS RIVER
Practice Address - State:NJ
Practice Address - Zip Code:08753-4605
Practice Address - Country:US
Practice Address - Phone:732-929-3440
Practice Address - Fax:732-929-0920
Is Sole Proprietor?:No
Enumeration Date:2021-03-01
Last Update Date:2021-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RI04201500183500000X
PAPI121714183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist