Provider Demographics
NPI:1962478941
Name:FULLER, ROBERT EDGAR (PHRAM D)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:EDGAR
Last Name:FULLER
Suffix:
Gender:M
Credentials:PHRAM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 LANDFALL CT
Mailing Address - Street 2:
Mailing Address - City:NEWPORT
Mailing Address - State:NC
Mailing Address - Zip Code:28570-5570
Mailing Address - Country:US
Mailing Address - Phone:910-450-4180
Mailing Address - Fax:
Practice Address - Street 1:100 BREWSTER BLVD
Practice Address - Street 2:NAVAL HOSPITAL CAMP LEJEUNE
Practice Address - City:CAMP LEJEUNE
Practice Address - State:NC
Practice Address - Zip Code:28547-2538
Practice Address - Country:US
Practice Address - Phone:910-450-4180
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9032N183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist