Provider Demographics
NPI:1679804173
Name:KEAGLE, FULTON (RPH)
Entity Type:Individual
Prefix:
First Name:FULTON
Middle Name:
Last Name:KEAGLE
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 1:33 PONDEROSA CT
Mailing Address - Street 2:
Mailing Address - City:ORCHARD PARK
Mailing Address - State:NY
Mailing Address - Zip Code:14127-2070
Mailing Address - Country:US
Mailing Address - Phone:716-667-3631
Mailing Address - Fax:
Practice Address - Street 1:2355 UNION RD
Practice Address - Street 2:
Practice Address - City:CHEEKTOWAGA
Practice Address - State:NY
Practice Address - Zip Code:14227-2234
Practice Address - Country:US
Practice Address - Phone:716-631-2433
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-01-22
Last Update Date:2010-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY029223183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist