Provider Demographics
NPI:1952466252
Name:FULLERTON, JILL ANNE (RPH)
Entity Type:Individual
Prefix:MISS
First Name:JILL
Middle Name:ANNE
Last Name:FULLERTON
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 1:1269 MCKINLEY ST
Mailing Address - Street 2:
Mailing Address - City:ENUMCLAW
Mailing Address - State:WA
Mailing Address - Zip Code:98022-2106
Mailing Address - Country:US
Mailing Address - Phone:360-825-5525
Mailing Address - Fax:360-825-5525
Practice Address - Street 1:1269 MCKINLEY ST
Practice Address - Street 2:
Practice Address - City:ENUMCLAW
Practice Address - State:WA
Practice Address - Zip Code:98022-2106
Practice Address - Country:US
Practice Address - Phone:360-825-5525
Practice Address - Fax:360-825-5525
Is Sole Proprietor?:No
Enumeration Date:2006-12-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA13637183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA13637OtherPHARMACIST LICENSE