=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790829067
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ROBERT IRWIN FULFORD R.PH.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/19/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2300 TREASURY DR SE
-----------------------------------------------------
City | CLEVELAND
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37323-7185
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 423-472-0656
-----------------------------------------------------
Fax | 423-472-0557
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 440 HICKS BRANCH RD
-----------------------------------------------------
City | RELIANCE
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37369-4421
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 423-338-4349
-----------------------------------------------------
Fax | 423-338-2253
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 11833
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------