Provider Demographics
NPI:1871596791
Name:BULLOCK, CLINTON D (RPH, NCPS)
Entity type:Individual
Prefix:MR
First Name:CLINTON
Middle Name:D
Last Name:BULLOCK
Suffix:
Gender:M
Credentials:RPH, NCPS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 CHOCTAW WAY
Mailing Address - Street 2:
Mailing Address - City:TALIHINA
Mailing Address - State:OK
Mailing Address - Zip Code:74571-2022
Mailing Address - Country:US
Mailing Address - Phone:918-567-7000
Mailing Address - Fax:918-567-7134
Practice Address - Street 1:1 CHOCTAW WAY
Practice Address - Street 2:
Practice Address - City:TALIHINA
Practice Address - State:OK
Practice Address - Zip Code:74571-2022
Practice Address - Country:US
Practice Address - Phone:918-567-7000
Practice Address - Fax:918-567-7134
Is Sole Proprietor?:Yes
Enumeration Date:2005-05-24
Last Update Date:2018-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO0435921835P1200X
OK15401183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
No1835P1200XPharmacy Service ProvidersPharmacistPharmacotherapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK1871596791Medicare UPIN