Provider Demographics
NPI:1508901174
Name:FULLMER, JAMES DARRELL (RPH)
Entity Type:Individual
Prefix:MR
First Name:JAMES
Middle Name:DARRELL
Last Name:FULLMER
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 1:475 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:EPHRAIM
Mailing Address - State:UT
Mailing Address - Zip Code:84627-4017
Mailing Address - Country:US
Mailing Address - Phone:435-283-0340
Mailing Address - Fax:
Practice Address - Street 1:475 S MAIN ST
Practice Address - Street 2:
Practice Address - City:EPHRAIM
Practice Address - State:UT
Practice Address - Zip Code:84627-4017
Practice Address - Country:US
Practice Address - Phone:435-283-0340
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-21
Last Update Date:2010-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT130934183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist