Provider Demographics
NPI:1891257622
Name:FULTS, MINDY ANN (RPH)
Entity Type:Individual
Prefix:
First Name:MINDY
Middle Name:ANN
Last Name:FULTS
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3068 OVERLAND AVE
Mailing Address - Street 2:
Mailing Address - City:ROWLEY
Mailing Address - State:IA
Mailing Address - Zip Code:52329-9793
Mailing Address - Country:US
Mailing Address - Phone:319-721-8198
Mailing Address - Fax:
Practice Address - Street 1:302 ENTERPRISE DR
Practice Address - Street 2:
Practice Address - City:INDEPENDENCE
Practice Address - State:IA
Practice Address - Zip Code:50644-9601
Practice Address - Country:US
Practice Address - Phone:319-334-7131
Practice Address - Fax:319-334-7133
Is Sole Proprietor?:No
Enumeration Date:2019-04-01
Last Update Date:2019-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA18408183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA18408OtherIOWA BOARD OF PHARMACY