Provider Demographics
NPI:1295329258
Name:MULLEN, MARK ALLEN (RPH)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:ALLEN
Last Name:MULLEN
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6811 23RD AVE W
Mailing Address - Street 2:
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34209-5435
Mailing Address - Country:US
Mailing Address - Phone:941-744-6163
Mailing Address - Fax:941-798-9732
Practice Address - Street 1:6811 23RD AVE W
Practice Address - Street 2:
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34209-5435
Practice Address - Country:US
Practice Address - Phone:941-744-6163
Practice Address - Fax:941-798-9732
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-21
Last Update Date:2021-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS15727183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist