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General NPI Number Information
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NPI Number | 1124303250
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Entity Type | Individual
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Provider Name | SALLY SUZANNE FULLENKAMP PHARM D.
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Gender | Female
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Dates
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Enumeration Date | 10/20/2011
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Last Update Date | 10/20/2011
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Provider Practice Location Address
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Address Line | 10314 FLORENCE CIR
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City | LA VISTA
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State | NE
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Zip | 68128-2372
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Country | US
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Telephone | 402-504-9932
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Fax |
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Provider Business Mailing Address
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Address Line | 10314 FLORENCE CIR
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City | LA VISTA
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State | NE
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Zip | 68128-2372
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Country | US
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Telephone | 402-504-9932
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 183500000X
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Taxonomy Name | Pharmacist
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License Number | 13121
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License Number State | NE
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Taxonomy #2
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Taxonomy Code | 183500000X
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Taxonomy Name | Pharmacist
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License Number | 2007028067
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License Number State | MO
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