Provider Demographics
NPI:1134203268
Name:FULTON ROAD PHARMACY INC
Entity type:Organization
Organization Name:FULTON ROAD PHARMACY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:
Authorized Official - Last Name:KINGSBURY
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:330-456-2476
Mailing Address - Street 1:1657 25TH ST NW
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44709-3421
Mailing Address - Country:US
Mailing Address - Phone:330-456-2476
Mailing Address - Fax:330-456-1973
Practice Address - Street 1:1657 25TH ST NW
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44709-3421
Practice Address - Country:US
Practice Address - Phone:330-456-2476
Practice Address - Fax:330-456-1973
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-25
Last Update Date:2016-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
OH0212969003336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2078516OtherPK
OH2286477Medicaid
OH2286477Medicaid