Provider Demographics
NPI:1912042094
Name:BULLEN, JACK EDWARD (DPH)
Entity Type:Individual
Prefix:MR
First Name:JACK
Middle Name:EDWARD
Last Name:BULLEN
Suffix:
Gender:M
Credentials:DPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 STRATFORD DR
Mailing Address - Street 2:
Mailing Address - City:GREENEVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37743-6638
Mailing Address - Country:US
Mailing Address - Phone:423-639-4354
Mailing Address - Fax:423-638-3311
Practice Address - Street 1:239 W SUMMER ST
Practice Address - Street 2:
Practice Address - City:GREENEVILLE
Practice Address - State:TN
Practice Address - Zip Code:37743-4925
Practice Address - Country:US
Practice Address - Phone:423-638-4711
Practice Address - Fax:423-638-3311
Is Sole Proprietor?:No
Enumeration Date:2007-02-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN458183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1454403Medicaid
TN1454403Medicaid