Provider Demographics
NPI:1669680997
Name:FULLER, CLIVE (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:CLIVE
Middle Name:
Last Name:FULLER
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 1:105 N BASCOM AVE STE 101
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95128-1811
Mailing Address - Country:US
Mailing Address - Phone:408-995-6020
Mailing Address - Fax:
Practice Address - Street 1:105 N BASCOM AVE STE 101
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95128-1811
Practice Address - Country:US
Practice Address - Phone:408-995-6020
Practice Address - Fax:408-995-5320
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARPH 43998183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist