Provider Demographics
NPI:1093704371
Name:FULTON PHARMACY INC
Entity Type:Organization
Organization Name:FULTON PHARMACY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:SUZANNE
Authorized Official - Middle Name:NASH
Authorized Official - Last Name:ANTHONY
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:616-791-2014
Mailing Address - Street 1:4291 MOHAVE CT SW
Mailing Address - Street 2:
Mailing Address - City:GRANDVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:49418-1739
Mailing Address - Country:US
Mailing Address - Phone:616-293-1258
Mailing Address - Fax:
Practice Address - Street 1:738 W FULTON ST
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49504-6320
Practice Address - Country:US
Practice Address - Phone:616-293-1258
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-19
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5301005576333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4734275Medicaid
2348678OtherNABP
MI2348678Medicaid
BF2683793OtherDEA