Provider Demographics
NPI:1275707705
Name:FULLER, JODY DOW (RPH)
Entity Type:Individual
Prefix:MR
First Name:JODY
Middle Name:DOW
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:PO BOX 690
Mailing Address - Street 2:
Mailing Address - City:POUNDING MILL
Mailing Address - State:VA
Mailing Address - Zip Code:24637-0690
Mailing Address - Country:US
Mailing Address - Phone:276-963-3502
Mailing Address - Fax:276-963-3757
Practice Address - Street 1:12252 GOVERNOR GC PEERY HIGHWAY
Practice Address - Street 2:
Practice Address - City:POUNDING MILL
Practice Address - State:VA
Practice Address - Zip Code:24637
Practice Address - Country:US
Practice Address - Phone:276-963-3502
Practice Address - Fax:276-963-3757
Is Sole Proprietor?:No
Enumeration Date:2008-04-16
Last Update Date:2008-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202204610183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist