Provider Demographics
NPI:1396798781
Name:BULLOCK, JEREL (RPH)
Entity type:Individual
Prefix:
First Name:JEREL
Middle Name:
Last Name:BULLOCK
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 1:1091 W SOUTH JORDAN PKWY
Mailing Address - Street 2:SUITE 500
Mailing Address - City:SOUTH JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84095-8820
Mailing Address - Country:US
Mailing Address - Phone:801-213-9850
Mailing Address - Fax:801-213-9855
Practice Address - Street 1:1091 W SOUTH JORDAN PKWY
Practice Address - Street 2:SUITE 500
Practice Address - City:SOUTH JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84095-8820
Practice Address - Country:US
Practice Address - Phone:801-213-9850
Practice Address - Fax:801-213-9855
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT339863-1701183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist