Provider Demographics
NPI:1396043410
Name:FULCO, KYLA G (PHARM D)
Entity Type:Individual
Prefix:
First Name:KYLA
Middle Name:G
Last Name:FULCO
Suffix:
Gender:F
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5711 YOUREE DR
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71105-4216
Mailing Address - Country:US
Mailing Address - Phone:318-868-3621
Mailing Address - Fax:318-866-2646
Practice Address - Street 1:5711 YOUREE DR
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71105-4216
Practice Address - Country:US
Practice Address - Phone:318-868-3621
Practice Address - Fax:318-866-2646
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-14
Last Update Date:2011-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA018218183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist