Provider Demographics
NPI:1033706387
Name:FULLERTON, JOHN CARR IV (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:CARR
Last Name:FULLERTON
Suffix:IV
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 1:223 1/2 N TEMPLE DR.
Mailing Address - Street 2:
Mailing Address - City:DIBOLL
Mailing Address - State:TX
Mailing Address - Zip Code:75941
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:223 1/2 N TEMPLE DR.
Practice Address - Street 2:
Practice Address - City:DIBOLL
Practice Address - State:TX
Practice Address - Zip Code:75941
Practice Address - Country:US
Practice Address - Phone:936-829-3671
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-21
Last Update Date:2020-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX52433183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist