Healthcare Provider Details

I. General information

NPI: 1417039470
Provider Name (Legal Business Name): MATTHEW A. FULLER PHARM.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/19/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10000 BRECKSVILLE RD PHARMACY SERVICE 119 (B)
BRECKSVILLE OH
44141-3204
US

IV. Provider business mailing address

10000 BRECKSVILLE RD PHARMACY SERVICE 119 (B)
BRECKSVILLE OH
44141-3204
US

V. Phone/Fax

Practice location:
  • Phone: 440-526-3030
  • Fax: 440-546-2706
Mailing address:
  • Phone: 440-526-3030
  • Fax: 440-546-2706

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P1300X
TaxonomyPsychiatric Pharmacist
License Number03-2-15158
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: