Provider Demographics
NPI:1164692745
Name:FULLERTON MEDICAL PHARMACY INC
Entity Type:Organization
Organization Name:FULLERTON MEDICAL PHARMACY INC
Other - Org Name:FULLERTON MEDICAL PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:HEAD PHARMACIST/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:INSEEK
Authorized Official - Middle Name:
Authorized Official - Last Name:HAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:714-992-4908
Mailing Address - Street 1:1401 S BROOKHURST RD
Mailing Address - Street 2:STE 101
Mailing Address - City:FULLERTON
Mailing Address - State:CA
Mailing Address - Zip Code:92833-4471
Mailing Address - Country:US
Mailing Address - Phone:714-992-4908
Mailing Address - Fax:714-992-2554
Practice Address - Street 1:1401 S BROOKHURST RD
Practice Address - Street 2:STE 101
Practice Address - City:FULLERTON
Practice Address - State:CA
Practice Address - Zip Code:92833-4471
Practice Address - Country:US
Practice Address - Phone:714-992-4908
Practice Address - Fax:714-992-2554
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-10
Last Update Date:2014-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA505473336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA6513510001Medicaid
2129447OtherPK
CA6513510001Medicaid