Provider Demographics
NPI:1417039470
Name:FULLER, MATTHEW A (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:A
Last Name:FULLER
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10000 BRECKSVILLE RD
Mailing Address - Street 2:PHARMACY SERVICE 119 (B)
Mailing Address - City:BRECKSVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:44141-3204
Mailing Address - Country:US
Mailing Address - Phone:440-526-3030
Mailing Address - Fax:440-546-2706
Practice Address - Street 1:10000 BRECKSVILLE RD
Practice Address - Street 2:PHARMACY SERVICE 119 (B)
Practice Address - City:BRECKSVILLE
Practice Address - State:OH
Practice Address - Zip Code:44141-3204
Practice Address - Country:US
Practice Address - Phone:440-526-3030
Practice Address - Fax:440-546-2706
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03-2-151581835P1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P1300XPharmacy Service ProvidersPharmacistPsychiatric