Provider Demographics
NPI:1225478845
Name:FULLER, HEATHER (PHARMD, MBA)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:
Last Name:FULLER
Suffix:
Gender:F
Credentials:PHARMD, MBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:420 LARUE RD
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:KY
Mailing Address - Zip Code:42420-3450
Mailing Address - Country:US
Mailing Address - Phone:270-831-0426
Mailing Address - Fax:
Practice Address - Street 1:1921 W PARRISH AVE
Practice Address - Street 2:
Practice Address - City:OWENSBORO
Practice Address - State:KY
Practice Address - Zip Code:42301-3542
Practice Address - Country:US
Practice Address - Phone:270-683-0223
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-27
Last Update Date:2015-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY016669183500000X
IN26025248A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist