Provider Demographics
NPI:1548645187
Name:FULP, JAMES
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:
Last Name:FULP
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 1:3 GASTON AVE
Mailing Address - Street 2:
Mailing Address - City:TIFTON
Mailing Address - State:GA
Mailing Address - Zip Code:31794-2075
Mailing Address - Country:US
Mailing Address - Phone:229-402-3164
Mailing Address - Fax:229-423-7147
Practice Address - Street 1:3 GASTON AVE
Practice Address - Street 2:
Practice Address - City:TIFTON
Practice Address - State:GA
Practice Address - Zip Code:31794-2075
Practice Address - Country:US
Practice Address - Phone:229-402-3164
Practice Address - Fax:229-423-7147
Is Sole Proprietor?:No
Enumeration Date:2015-07-24
Last Update Date:2015-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA9767183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist