Provider Demographics
NPI:1477702686
Name:FUSON, THEORA MAE (DPH)
Entity Type:Individual
Prefix:
First Name:THEORA
Middle Name:MAE
Last Name:FUSON
Suffix:
Gender:F
Credentials:DPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8634 HIGHWAY 58
Mailing Address - Street 2:
Mailing Address - City:HARRISON
Mailing Address - State:TN
Mailing Address - Zip Code:37341
Mailing Address - Country:US
Mailing Address - Phone:423-344-7261
Mailing Address - Fax:423-326-1962
Practice Address - Street 1:8634 HIGHWAY 58
Practice Address - Street 2:
Practice Address - City:HARRISON
Practice Address - State:TN
Practice Address - Zip Code:37341
Practice Address - Country:US
Practice Address - Phone:423-344-7261
Practice Address - Fax:423-326-1962
Is Sole Proprietor?:No
Enumeration Date:2008-09-11
Last Update Date:2008-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN219183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist