Provider Demographics
NPI:1326637810
Name:FULLER, BRENT (RPH)
Entity Type:Individual
Prefix:
First Name:BRENT
Middle Name:
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 1:339 9TH AVE SW
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:AL
Mailing Address - Zip Code:36862-2896
Mailing Address - Country:US
Mailing Address - Phone:334-864-7781
Mailing Address - Fax:
Practice Address - Street 1:339 9TH AVE SW
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:AL
Practice Address - Zip Code:36862-2896
Practice Address - Country:US
Practice Address - Phone:334-864-7781
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-11
Last Update Date:2021-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL13653183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist