Provider Demographics
NPI:1588736581
Name:FAULK, BRUCE MICHAEL (RPH)
Entity type:Individual
Prefix:
First Name:BRUCE
Middle Name:MICHAEL
Last Name:FAULK
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 1:303 S JEFFERSON AVE
Mailing Address - Street 2:
Mailing Address - City:EATONTON
Mailing Address - State:GA
Mailing Address - Zip Code:31024-1129
Mailing Address - Country:US
Mailing Address - Phone:706-485-7945
Mailing Address - Fax:706-485-2122
Practice Address - Street 1:303 S JEFFERSON AVE
Practice Address - Street 2:
Practice Address - City:EATONTON
Practice Address - State:GA
Practice Address - Zip Code:31024-1129
Practice Address - Country:US
Practice Address - Phone:706-485-6262
Practice Address - Fax:706-485-2122
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA012293183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist