Provider Demographics
NPI:1538416623
Name:FULLER, COURTNEY MIDGETTE (RPH)
Entity type:Individual
Prefix:MRS
First Name:COURTNEY
Middle Name:MIDGETTE
Last Name:FULLER
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2621 GROVE AVE
Mailing Address - Street 2:RETREAT DOCTORS' HOSPITAL PHARMACY
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23220-4308
Mailing Address - Country:US
Mailing Address - Phone:804-254-5572
Mailing Address - Fax:
Practice Address - Street 1:2621 GROVE AVE
Practice Address - Street 2:RETREAT DOCTORS' HOSPITAL PHARMACY
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23220-4308
Practice Address - Country:US
Practice Address - Phone:804-254-5572
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-08
Last Update Date:2012-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202010089183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist