Provider Demographics
NPI:1306414792
Name:FULKERT, DONALD J (RPH)
Entity Type:Individual
Prefix:MR
First Name:DONALD
Middle Name:J
Last Name:FULKERT
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 1:809 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:GENOA
Mailing Address - State:OH
Mailing Address - Zip Code:43430-1637
Mailing Address - Country:US
Mailing Address - Phone:419-855-4091
Mailing Address - Fax:
Practice Address - Street 1:2600 NAVARRE AVE
Practice Address - Street 2:
Practice Address - City:OREGON
Practice Address - State:OH
Practice Address - Zip Code:43616-3207
Practice Address - Country:US
Practice Address - Phone:419-696-7595
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-14
Last Update Date:2021-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03216683183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH360081Medicaid