Healthcare Provider Details

I. General information

NPI: 1699691899
Provider Name (Legal Business Name): ALISSA FULLER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/24/2026
Last Update Date: 06/24/2026
Certification Date: 06/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4725 N FEDERAL HWY
FORT LAUDERDALE FL
33308-4603
US

IV. Provider business mailing address

4725 N FEDERAL HWY
FORT LAUDERDALE FL
33308-4603
US

V. Phone/Fax

Practice location:
  • Phone: 954-542-3195
  • Fax:
Mailing address:
  • Phone: 954-542-3195
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberPS26779
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: