Provider Demographics
NPI:1114479102
Name:FULLER, DANIEL R JR (PHARMD)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:R
Last Name:FULLER
Suffix:JR
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 1:7500 UNIVSERSITY BLVD.
Mailing Address - Street 2:
Mailing Address - City:MOON TOWNSHIP
Mailing Address - State:PA
Mailing Address - Zip Code:15108
Mailing Address - Country:US
Mailing Address - Phone:412-893-0143
Mailing Address - Fax:
Practice Address - Street 1:7500 UNIVSERSITY BLVD.
Practice Address - Street 2:
Practice Address - City:MOON TOWNSHIP
Practice Address - State:PA
Practice Address - Zip Code:15108
Practice Address - Country:US
Practice Address - Phone:412-893-0143
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-26
Last Update Date:2016-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARP449801183500000X
PARPI009891183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PARPI009891OtherPENNSYLVANIA BOARD OF PHARMACY
PARP449801OtherPENNSYLVANIA BOARD OF PHARMACY