Provider Demographics
NPI:1063968048
Name:FULLER, KEITH
Entity type:Individual
Prefix:
First Name:KEITH
Middle Name:
Last Name:FULLER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2274 FEDSCREEK RD
Mailing Address - Street 2:
Mailing Address - City:STEELE
Mailing Address - State:KY
Mailing Address - Zip Code:41566-8515
Mailing Address - Country:US
Mailing Address - Phone:606-371-4856
Mailing Address - Fax:
Practice Address - Street 1:11349 ST HWY 1056
Practice Address - Street 2:
Practice Address - City:MCCARR
Practice Address - State:KY
Practice Address - Zip Code:41544
Practice Address - Country:US
Practice Address - Phone:606-427-9007
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-30
Last Update Date:2016-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY012854183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist