Healthcare Provider Details

I. General information

NPI: 1093704371
Provider Name (Legal Business Name): FULTON PHARMACY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/19/2005
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

738 W FULTON ST
GRAND RAPIDS MI
49504-6320
US

IV. Provider business mailing address

4291 MOHAVE CT SW
GRANDVILLE MI
49418-1739
US

V. Phone/Fax

Practice location:
  • Phone: 616-293-1258
  • Fax:
Mailing address:
  • Phone: 616-293-1258
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number5301005576
License Number StateMI

VIII. Authorized Official

Name: MRS. SUZANNE NASH ANTHONY
Title or Position: VICE PRESIDENT
Credential: RPH
Phone: 616-791-2014