Provider Demographics
NPI:1528877594
Name:BULLOCK, BURGUNDIE (PHARMD)
Entity type:Individual
Prefix:
First Name:BURGUNDIE
Middle Name:
Last Name:BULLOCK
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:456 SUNFLOWER RD
Mailing Address - Street 2:
Mailing Address - City:REXBURG
Mailing Address - State:ID
Mailing Address - Zip Code:83440-4921
Mailing Address - Country:US
Mailing Address - Phone:208-220-8231
Mailing Address - Fax:
Practice Address - Street 1:2252 CORONADO ST
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-7552
Practice Address - Country:US
Practice Address - Phone:208-523-3360
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-01-04
Last Update Date:2025-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDI75864183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist