Provider Demographics
NPI:1477804094
Name:FULLWOOD, DAVON (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:DAVON
Middle Name:
Last Name:FULLWOOD
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 1:2007 MADISON AVE
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21217-3861
Mailing Address - Country:US
Mailing Address - Phone:443-762-7397
Mailing Address - Fax:
Practice Address - Street 1:6323 BALTIMORE NATIONAL PIKE
Practice Address - Street 2:
Practice Address - City:CATONSVILLE
Practice Address - State:MD
Practice Address - Zip Code:21228-3902
Practice Address - Country:US
Practice Address - Phone:410-744-0306
Practice Address - Fax:410-744-7470
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-21
Last Update Date:2012-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD20738183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist