Provider Demographics
NPI:1235278904
Name:CULLER, GERALD LYN
Entity Type:Individual
Prefix:
First Name:GERALD
Middle Name:LYN
Last Name:CULLER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3729 ROSEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29205-3531
Mailing Address - Country:US
Mailing Address - Phone:803-231-2003
Mailing Address - Fax:803-231-2004
Practice Address - Street 1:3729 ROSEWOOD DR
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29205-3531
Practice Address - Country:US
Practice Address - Phone:803-231-2003
Practice Address - Fax:803-231-2004
Is Sole Proprietor?:No
Enumeration Date:2007-02-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC004589183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC767123Medicaid