=====================================================
General NPI Number Information
=====================================================
NPI Number | 1144636374
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ROBERT FULGHAM PHD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/09/2014
-----------------------------------------------------
Last Update Date | 01/12/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1734 CARTER HILL RD
-----------------------------------------------------
City | MONTGOMERY
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 36106-2002
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 334-263-3818
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 100 ELBA HWY
-----------------------------------------------------
City | TROY
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 36079-5467
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 334-808-4282
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 15132
-----------------------------------------------------
License Number State | AL
-----------------------------------------------------