Provider Demographics
NPI:1235267931
Name:FULLER, GREGORY ALAN (RPH)
Entity Type:Individual
Prefix:MR
First Name:GREGORY
Middle Name:ALAN
Last Name:FULLER
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 CHAPEL ST.
Mailing Address - Street 2:PO BOX 185
Mailing Address - City:SHERBURNE
Mailing Address - State:NY
Mailing Address - Zip Code:13460
Mailing Address - Country:US
Mailing Address - Phone:607-674-6555
Mailing Address - Fax:315-824-5710
Practice Address - Street 1:103 UTICA ST
Practice Address - Street 2:
Practice Address - City:HAMILTON
Practice Address - State:NY
Practice Address - Zip Code:13346-1100
Practice Address - Country:US
Practice Address - Phone:315-824-2200
Practice Address - Fax:315-824-5710
Is Sole Proprietor?:No
Enumeration Date:2007-03-02
Last Update Date:2010-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY032488183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist