Provider Demographics
NPI:1023621232
Name:WHITE BULL, THOMAS ALAN GOOD LANCE (CPHT)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:ALAN GOOD LANCE
Last Name:WHITE BULL
Suffix:
Gender:M
Credentials:CPHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:809 AVALON HILLS DR
Mailing Address - Street 2:
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84404-6654
Mailing Address - Country:US
Mailing Address - Phone:801-928-1269
Mailing Address - Fax:
Practice Address - Street 1:500 FOOTHILL DR
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84148-0001
Practice Address - Country:US
Practice Address - Phone:801-582-1565
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-26
Last Update Date:2020-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT9752695-1717183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician