Healthcare Provider Details

I. General information

NPI: 1710800867
Provider Name (Legal Business Name): FREDRICK CULLISON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/04/2026
Last Update Date: 08/04/2026
Certification Date: 08/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

103 E HACKBERRY ST
SALEM IN
47167-2001
US

IV. Provider business mailing address

5158 S EASTERN SCHOOL RD
PEKIN IN
47165-8011
US

V. Phone/Fax

Practice location:
  • Phone: 812-883-6929
  • Fax:
Mailing address:
  • Phone: 812-620-6131
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number26027420A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: