Provider Demographics
NPI:1114309713
Name:FULLARD, KHALILAH (PHARMD)
Entity Type:Individual
Prefix:
First Name:KHALILAH
Middle Name:
Last Name:FULLARD
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:50 HOSPITAL HILL RD
Mailing Address - Street 2:
Mailing Address - City:SHARON
Mailing Address - State:CT
Mailing Address - Zip Code:06069-2096
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:50 HOSPITAL HILL RD
Practice Address - Street 2:
Practice Address - City:SHARON
Practice Address - State:CT
Practice Address - Zip Code:06069-2096
Practice Address - Country:US
Practice Address - Phone:860-364-4026
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-19
Last Update Date:2015-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTPCT.9972183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist