MEDICARE: CHANTE FULLER

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	PS59704	FL

General Provider Information

NPI Number	:	1588257885
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHANTE FULLER

Provider Business Mailing Address
First Line	:	8928 PROMINENCE PKWY # 200
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32256-8264
Country	:	US
Telephone Number	:	904-783-5000
Fax Number	:

Provider Business Practice Location Address
First Line	:	14600 PALM BEACH BLVD
Second Line	:
City	:	FORT MYERS
State	:	FL
Zip	:	33905-2302
Country	:	US
Telephone Number	:	239-693-6944
Fax Number	:

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

Provider Enumeration Date	:	02/17/2021
Last Update Date	:	02/17/2021

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Directions to “ CHANTE FULLER ” Practice Location

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