Provider Demographics
NPI:1255044822
Name:FULTZ, KEIRSTIAN
Entity type:Individual
Prefix:
First Name:KEIRSTIAN
Middle Name:
Last Name:FULTZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21287 HIGHWAY 421
Mailing Address - Street 2:
Mailing Address - City:HYDEN
Mailing Address - State:KY
Mailing Address - Zip Code:41749-8554
Mailing Address - Country:US
Mailing Address - Phone:606-672-3811
Mailing Address - Fax:606-672-3926
Practice Address - Street 1:21287 HIGHWAY 421
Practice Address - Street 2:
Practice Address - City:HYDEN
Practice Address - State:KY
Practice Address - Zip Code:41749-8554
Practice Address - Country:US
Practice Address - Phone:606-672-3811
Practice Address - Fax:606-672-3926
Is Sole Proprietor?:No
Enumeration Date:2022-12-28
Last Update Date:2022-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY022932183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist