Provider Demographics
NPI:1750981106
Name:FULLER, NATASHA RENEE (PHARMD)
Entity type:Individual
Prefix:MRS
First Name:NATASHA
Middle Name:RENEE
Last Name:FULLER
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:35 TIMS ORCHARD RD
Mailing Address - Street 2:
Mailing Address - City:TROUTVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24175-7158
Mailing Address - Country:US
Mailing Address - Phone:276-210-7842
Mailing Address - Fax:
Practice Address - Street 1:4524 CHALLENGER AVE
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24012-7028
Practice Address - Country:US
Practice Address - Phone:540-977-4881
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-27
Last Update Date:2020-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202210888183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist