Provider Demographics
NPI:1942411285
Name:BULLOUGH, LISA ANN (RPH)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:ANN
Last Name:BULLOUGH
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:ANN
Other - Last Name:ROBINSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RPH
Mailing Address - Street 1:5681 SIERRA GRANDE DR
Mailing Address - Street 2:
Mailing Address - City:TAYLORSVILLE
Mailing Address - State:UT
Mailing Address - Zip Code:84118-2668
Mailing Address - Country:US
Mailing Address - Phone:801-964-0146
Mailing Address - Fax:
Practice Address - Street 1:3555 W 3500 S
Practice Address - Street 2:
Practice Address - City:WEST VALLEY CITY
Practice Address - State:UT
Practice Address - Zip Code:84119-2539
Practice Address - Country:US
Practice Address - Phone:801-963-6874
Practice Address - Fax:801-965-9953
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT144972183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist