Provider Demographics
NPI:1609862614
Name:BAKKE, BRUCE A (RPH, MBA)
Entity type:Individual
Prefix:
First Name:BRUCE
Middle Name:A
Last Name:BAKKE
Suffix:
Gender:M
Credentials:RPH, MBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:910 KINGS CANYON DR
Mailing Address - Street 2:
Mailing Address - City:GRAPEVINE
Mailing Address - State:TX
Mailing Address - Zip Code:76051-6643
Mailing Address - Country:US
Mailing Address - Phone:817-454-5541
Mailing Address - Fax:
Practice Address - Street 1:910 KINGS CANYON DR
Practice Address - Street 2:
Practice Address - City:GRAPEVINE
Practice Address - State:TX
Practice Address - Zip Code:76051-6643
Practice Address - Country:US
Practice Address - Phone:817-454-5541
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX30790183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist