Provider Demographics
NPI:1740536317
Name:FULLER, TIMOTHY EDWARD (PHARMD)
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:EDWARD
Last Name:FULLER
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31 TED DR
Mailing Address - Street 2:
Mailing Address - City:PINE BUSH
Mailing Address - State:NY
Mailing Address - Zip Code:12566-7032
Mailing Address - Country:US
Mailing Address - Phone:845-744-4827
Mailing Address - Fax:
Practice Address - Street 1:31 TED DR
Practice Address - Street 2:
Practice Address - City:PINE BUSH
Practice Address - State:NY
Practice Address - Zip Code:12566-7032
Practice Address - Country:US
Practice Address - Phone:845-744-4827
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-31
Last Update Date:2020-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY056811183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist