MEDICARE: LISA ARIELLE FULLERTON RPH

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	01322686	OH

General Provider Information

NPI Number	:	1528350410
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LISA ARIELLE FULLERTON RPH

Provider Business Mailing Address
First Line	:	1475 LANDER RD
Second Line	:
City	:	MAYFIELD HEIGHTS
State	:	OH
Zip	:	44124-3358
Country	:	US
Telephone Number	:	216-816-2277
Fax Number	:

Provider Business Practice Location Address
First Line	:	1475 LANDER RD
Second Line	:
City	:	MAYFIELD HEIGHTS
State	:	OH
Zip	:	44124-3358
Country	:	US
Telephone Number	:	216-816-2277
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/10/2011
Last Update Date	:	05/10/2011

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