Provider Demographics
NPI:1477321560
Name:FULLER, SCOTT MICHAEL (RPH)
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:MICHAEL
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 1:1765 MIDDLESEX ST
Mailing Address - Street 2:
Mailing Address - City:LOWELL
Mailing Address - State:MA
Mailing Address - Zip Code:01851-1105
Mailing Address - Country:US
Mailing Address - Phone:978-323-7813
Mailing Address - Fax:978-323-7843
Practice Address - Street 1:1765 MIDDLESEX ST
Practice Address - Street 2:
Practice Address - City:LOWELL
Practice Address - State:MA
Practice Address - Zip Code:01851-1105
Practice Address - Country:US
Practice Address - Phone:978-323-7813
Practice Address - Fax:978-323-7843
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-18
Last Update Date:2023-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NHR1183183500000X
MAPH20135183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist