Provider Demographics
NPI:1215668603
Name:FULLER, GREGORY ROSS (RPH)
Entity type:Individual
Prefix:
First Name:GREGORY
Middle Name:ROSS
Last Name:FULLER
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1725 COUNTY ROAD 301
Mailing Address - Street 2:
Mailing Address - City:ALTON
Mailing Address - State:MO
Mailing Address - Zip Code:65606-8311
Mailing Address - Country:US
Mailing Address - Phone:417-280-6270
Mailing Address - Fax:
Practice Address - Street 1:270 MAIN ST
Practice Address - Street 2:
Practice Address - City:MAMMOTH SPRING
Practice Address - State:AR
Practice Address - Zip Code:72554-7466
Practice Address - Country:US
Practice Address - Phone:870-625-3222
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-17
Last Update Date:2022-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPD16070183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist