Provider Demographics
NPI:1255935938
Name:DOVIN, BRUCE J
Entity type:Individual
Prefix:
First Name:BRUCE
Middle Name:J
Last Name:DOVIN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 S OAK ST
Mailing Address - Street 2:
Mailing Address - City:ADVANCE
Mailing Address - State:MO
Mailing Address - Zip Code:63730-8343
Mailing Address - Country:US
Mailing Address - Phone:573-722-3562
Mailing Address - Fax:
Practice Address - Street 1:110 S OAK ST
Practice Address - Street 2:
Practice Address - City:ADVANCE
Practice Address - State:MO
Practice Address - Zip Code:63730-8343
Practice Address - Country:US
Practice Address - Phone:573-722-3562
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-24
Last Update Date:2020-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO044126183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO601827405Medicaid