Provider Demographics
NPI:1851833545
Name:FULLER, RUAL JR (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:RUAL
Middle Name:
Last Name:FULLER
Suffix:JR
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 1:3419 ORANGE AVE NE
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24012-6422
Mailing Address - Country:US
Mailing Address - Phone:540-283-5128
Mailing Address - Fax:540-283-5122
Practice Address - Street 1:3419 ORANGE AVE NE
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24012-6422
Practice Address - Country:US
Practice Address - Phone:540-283-5128
Practice Address - Fax:540-283-5122
Is Sole Proprietor?:No
Enumeration Date:2016-11-10
Last Update Date:2016-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202210171183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist