Provider Demographics
NPI:1124303250
Name:FULLENKAMP, SALLY SUZANNE (PHARM D)
Entity type:Individual
Prefix:
First Name:SALLY
Middle Name:SUZANNE
Last Name:FULLENKAMP
Suffix:
Gender:F
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10314 FLORENCE CIR
Mailing Address - Street 2:
Mailing Address - City:LA VISTA
Mailing Address - State:NE
Mailing Address - Zip Code:68128-2372
Mailing Address - Country:US
Mailing Address - Phone:402-504-9932
Mailing Address - Fax:
Practice Address - Street 1:10314 FLORENCE CIR
Practice Address - Street 2:
Practice Address - City:LA VISTA
Practice Address - State:NE
Practice Address - Zip Code:68128-2372
Practice Address - Country:US
Practice Address - Phone:402-504-9932
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-20
Last Update Date:2011-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE13121183500000X
MO2007028067183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist