Provider Demographics
NPI:1447566476
Name:BULLOCK, NATHAN (PHARMD)
Entity Type:Individual
Prefix:
First Name:NATHAN
Middle Name:
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 1:743 W MEADOW SIDE DR
Mailing Address - Street 2:
Mailing Address - City:SARATOGA SPRINGS
Mailing Address - State:UT
Mailing Address - Zip Code:84045-5316
Mailing Address - Country:US
Mailing Address - Phone:801-494-5092
Mailing Address - Fax:
Practice Address - Street 1:1324 N STATE ST
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84604-2419
Practice Address - Country:US
Practice Address - Phone:801-374-2015
Practice Address - Fax:801-374-9954
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-27
Last Update Date:2010-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6023383-1701183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist