Healthcare Provider Details

I. General information

NPI: 1154341394
Provider Name (Legal Business Name): DENNIS KEITH FULLER PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/20/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2300 S RANCHO DR 205
LAS VEGAS NV
89102-4506
US

IV. Provider business mailing address

4833 SPANISH WELLS DR
NORTH LAS VEGAS NV
89031-5545
US

V. Phone/Fax

Practice location:
  • Phone: 702-383-2691
  • Fax: 702-388-4186
Mailing address:
  • Phone: 702-656-2238
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P1200X
TaxonomyPharmacotherapy Pharmacist
License Number10382
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: