Provider Demographics
NPI:1568297224
Name:BULLOUGH, HALEY (RPH)
Entity type:Individual
Prefix:
First Name:HALEY
Middle Name:
Last Name:BULLOUGH
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9 LAKE VILLAGE CT
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37601-1395
Mailing Address - Country:US
Mailing Address - Phone:615-788-2096
Mailing Address - Fax:
Practice Address - Street 1:112 SUNSET DR
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37604-2503
Practice Address - Country:US
Practice Address - Phone:423-283-0522
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-03
Last Update Date:2024-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202221452183500000X
TN0000047179183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist