Provider Demographics
NPI:1639449077
Name:FULLER, MARY RACHEL
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:RACHEL
Last Name:FULLER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:605 S PINELLAS AVE
Mailing Address - Street 2:
Mailing Address - City:TARPON SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:34689-3707
Mailing Address - Country:US
Mailing Address - Phone:727-942-1686
Mailing Address - Fax:727-944-2972
Practice Address - Street 1:605 S PINELLAS AVE
Practice Address - Street 2:
Practice Address - City:TARPON SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:34689-3707
Practice Address - Country:US
Practice Address - Phone:727-942-1686
Practice Address - Fax:727-944-2972
Is Sole Proprietor?:No
Enumeration Date:2012-01-03
Last Update Date:2012-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS36592183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist