Provider Demographics
NPI:1275828477
Name:FULLER, STEPHEN WELDON (RPH)
Entity Type:Individual
Prefix:MR
First Name:STEPHEN
Middle Name:WELDON
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 1:328 BETHEL DR
Mailing Address - Street 2:
Mailing Address - City:SALISBURY
Mailing Address - State:NC
Mailing Address - Zip Code:28144-2808
Mailing Address - Country:US
Mailing Address - Phone:704-637-2230
Mailing Address - Fax:
Practice Address - Street 1:1706 W INNES ST
Practice Address - Street 2:
Practice Address - City:SALISBURY
Practice Address - State:NC
Practice Address - Zip Code:28144-2552
Practice Address - Country:US
Practice Address - Phone:704-636-1712
Practice Address - Fax:704-637-0324
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-15
Last Update Date:2011-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC05747183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist