Provider Demographics
NPI:1023386331
Name:FULLER, MARLON MONTY (PHARMD)
Entity Type:Individual
Prefix:MR
First Name:MARLON
Middle Name:MONTY
Last Name:FULLER
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2901 WEST HIGHWAY 74
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:NC
Mailing Address - Zip Code:28110
Mailing Address - Country:US
Mailing Address - Phone:704-282-1445
Mailing Address - Fax:
Practice Address - Street 1:2901 W HIGHWAY 74
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:NC
Practice Address - Zip Code:28110-8435
Practice Address - Country:US
Practice Address - Phone:704-282-1445
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-01
Last Update Date:2011-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC19123183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist