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General NPI Number Information
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NPI Number | 1376147660
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Entity Type | Individual
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Provider Name | TYKA FULLER PHARMD
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Gender | Female
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Dates
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Enumeration Date | 11/26/2020
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Last Update Date | 11/26/2020
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Provider Practice Location Address
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Address Line | 608 S MAIN ST
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City | HILLSBORO
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State | IL
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Zip | 62049-1732
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Country | US
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Telephone | 217-532-9477
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Fax |
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Provider Business Mailing Address
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Address Line | 6003 E 18TH RD
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City | COFFEEN
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State | IL
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Zip | 62017-2024
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Country | US
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Telephone | 618-975-1798
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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 | 051.291990
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License Number State | IL
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