Provider Demographics
NPI:1104532514
Name:PULLEN, MARYDETTE
Entity type:Individual
Prefix:
First Name:MARYDETTE
Middle Name:
Last Name:PULLEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4611 FALLING SUN DR
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77069-1035
Mailing Address - Country:US
Mailing Address - Phone:346-291-3464
Mailing Address - Fax:
Practice Address - Street 1:6635 N GRAND PKWY W
Practice Address - Street 2:
Practice Address - City:SPRING
Practice Address - State:TX
Practice Address - Zip Code:77389-1774
Practice Address - Country:US
Practice Address - Phone:832-717-0919
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-30
Last Update Date:2023-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX70504183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist