Provider Demographics
NPI:1629354147
Name:FUGATE, WILLAIM JASON (PHARMD)
Entity Type:Individual
Prefix:
First Name:WILLAIM
Middle Name:JASON
Last Name:FUGATE
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 1:3012 GROVEVIEW CT
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40214-3971
Mailing Address - Country:US
Mailing Address - Phone:502-813-1369
Mailing Address - Fax:
Practice Address - Street 1:3980 DIXIE HWY
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40216-4144
Practice Address - Country:US
Practice Address - Phone:502-447-4232
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-28
Last Update Date:2011-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY015557183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist