Provider Demographics
NPI:1104899574
Name:PRICKETT, FULLER MCIVER III
Entity type:Individual
Prefix:DR
First Name:FULLER
Middle Name:MCIVER
Last Name:PRICKETT
Suffix:III
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 1:300 E MCBEE AVE FL 4
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29601-2842
Mailing Address - Country:US
Mailing Address - Phone:803-434-6412
Mailing Address - Fax:
Practice Address - Street 1:1330 TAYLOR ST
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29201-2915
Practice Address - Country:US
Practice Address - Phone:803-296-5137
Practice Address - Fax:803-296-5499
Is Sole Proprietor?:No
Enumeration Date:2006-02-08
Last Update Date:2021-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC19571207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC195719Medicaid