MEDICARE: GREGORY ROSS FULLER RPH

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	PD16070	AR

General Provider Information

NPI Number	:	1215668603
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GREGORY ROSS FULLER RPH

Provider Business Mailing Address
First Line	:	1725 COUNTY ROAD 301
Second Line	:
City	:	ALTON
State	:	MO
Zip	:	65606-8311
Country	:	US
Telephone Number	:	417-280-6270
Fax Number	:

Provider Business Practice Location Address
First Line	:	270 MAIN ST
Second Line	:
City	:	MAMMOTH SPRING
State	:	AR
Zip	:	72554-7466
Country	:	US
Telephone Number	:	870-625-3222
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/17/2022
Last Update Date	:	06/17/2022

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