Provider Demographics
NPI:1093823445
Name:FULLER, LYNN M (RPH)
Entity Type:Individual
Prefix:MRS
First Name:LYNN
Middle Name:M
Last Name:FULLER
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2620 S 37 RD
Mailing Address - Street 2:
Mailing Address - City:CADILLAC
Mailing Address - State:MI
Mailing Address - Zip Code:49601-8127
Mailing Address - Country:US
Mailing Address - Phone:231-779-2879
Mailing Address - Fax:
Practice Address - Street 1:520 COBB ST
Practice Address - Street 2:
Practice Address - City:CADILLAC
Practice Address - State:MI
Practice Address - Zip Code:49601-2588
Practice Address - Country:US
Practice Address - Phone:231-876-6740
Practice Address - Fax:231-876-6739
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302411226183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist