Provider Demographics
NPI:1457687907
Name:FULLER, TRAVIS (PHARMD)
Entity Type:Individual
Prefix:
First Name:TRAVIS
Middle Name:
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 1:5098 SOUTHPORT SUPPLY RD SE
Mailing Address - Street 2:
Mailing Address - City:SOUTHPORT
Mailing Address - State:NC
Mailing Address - Zip Code:28461-8746
Mailing Address - Country:US
Mailing Address - Phone:910-457-1463
Mailing Address - Fax:
Practice Address - Street 1:5098 SOUTHPORT SUPPLY RD SE
Practice Address - Street 2:
Practice Address - City:SOUTHPORT
Practice Address - State:NC
Practice Address - Zip Code:28461-8746
Practice Address - Country:US
Practice Address - Phone:303-333-4678
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-19
Last Update Date:2022-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO21004183500000X
NC20363183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist