=====================================================
General NPI Number Information
=====================================================
NPI Number | 1376777854
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KIM L. FULMER R.PH.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/12/2009
-----------------------------------------------------
Last Update Date | 05/12/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 702 4TH AVE
-----------------------------------------------------
City | HOLDREGE
-----------------------------------------------------
State | NE
-----------------------------------------------------
Zip | 68949-2203
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 308-995-6105
-----------------------------------------------------
Fax | 308-995-6106
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 702 4TH AVE
-----------------------------------------------------
City | HOLDREGE
-----------------------------------------------------
State | NE
-----------------------------------------------------
Zip | 68949-2203
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 308-995-6105
-----------------------------------------------------
Fax | 308-995-6106
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 9471
-----------------------------------------------------
License Number State | NE
-----------------------------------------------------