Provider Demographics
NPI:1952917528
Name:FULLERTON PHARMACY, INC.
Entity Type:Organization
Organization Name:FULLERTON PHARMACY, INC.
Other - Org Name:FULLERTON PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO/CFO/SEC./DIR.
Authorized Official - Prefix:
Authorized Official - First Name:SIRISHA
Authorized Official - Middle Name:
Authorized Official - Last Name:PALAVALLI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:951-496-4222
Mailing Address - Street 1:1820 FULLERTON AVE.
Mailing Address - Street 2:STE. 105
Mailing Address - City:CORONA
Mailing Address - State:CA
Mailing Address - Zip Code:92881-3160
Mailing Address - Country:US
Mailing Address - Phone:951-496-4222
Mailing Address - Fax:
Practice Address - Street 1:1820 FULLERTON AVE.
Practice Address - Street 2:STE. 105
Practice Address - City:CORONA
Practice Address - State:CA
Practice Address - Zip Code:92881-3160
Practice Address - Country:US
Practice Address - Phone:951-496-4222
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-09-19
Last Update Date:2024-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy