Provider Demographics
NPI:1013405059
Name:FULPER, JODY E
Entity Type:Individual
Prefix:
First Name:JODY
Middle Name:E
Last Name:FULPER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2600 MCINGVALE RD
Mailing Address - Street 2:
Mailing Address - City:HERNANDO
Mailing Address - State:MS
Mailing Address - Zip Code:38632-8658
Mailing Address - Country:US
Mailing Address - Phone:662-429-8767
Mailing Address - Fax:662-429-8599
Practice Address - Street 1:2600 MCINGVALE RD
Practice Address - Street 2:
Practice Address - City:HERNANDO
Practice Address - State:MS
Practice Address - Zip Code:38632-8658
Practice Address - Country:US
Practice Address - Phone:662-429-8767
Practice Address - Fax:662-429-8599
Is Sole Proprietor?:No
Enumeration Date:2018-04-25
Last Update Date:2018-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSE-12940183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist