Provider Demographics
NPI:1336687722
Name:FULTZ, KENDRA
Entity Type:Individual
Prefix:
First Name:KENDRA
Middle Name:
Last Name:FULTZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13710 DESHLER RD
Mailing Address - Street 2:
Mailing Address - City:NORTH BALTIMORE
Mailing Address - State:OH
Mailing Address - Zip Code:45872-9794
Mailing Address - Country:US
Mailing Address - Phone:419-257-2221
Mailing Address - Fax:
Practice Address - Street 1:13710 DESHLER RD
Practice Address - Street 2:
Practice Address - City:NORTH BALTIMORE
Practice Address - State:OH
Practice Address - Zip Code:45872-9794
Practice Address - Country:US
Practice Address - Phone:419-257-2221
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-06
Last Update Date:2017-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03120606183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist