Provider Demographics
NPI:1821725128
Name:BULLINGTON, SOPHIA MISHELLE
Entity Type:Individual
Prefix:
First Name:SOPHIA
Middle Name:MISHELLE
Last Name:BULLINGTON
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 1:17602 FISHER RD
Mailing Address - Street 2:
Mailing Address - City:WEED
Mailing Address - State:CA
Mailing Address - Zip Code:96094-9432
Mailing Address - Country:US
Mailing Address - Phone:530-905-0661
Mailing Address - Fax:
Practice Address - Street 1:310 W LAKE ST
Practice Address - Street 2:
Practice Address - City:MOUNT SHASTA
Practice Address - State:CA
Practice Address - Zip Code:96067-2119
Practice Address - Country:US
Practice Address - Phone:530-926-3826
Practice Address - Fax:530-926-1279
Is Sole Proprietor?:No
Enumeration Date:2022-08-05
Last Update Date:2022-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CATCH187401183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician