Provider Demographics
NPI:1053782342
Name:FULLER, SUSAN GAYLE (PHARM D)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:GAYLE
Last Name:FULLER
Suffix:
Gender:F
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1504 S BROADWAY
Mailing Address - Street 2:
Mailing Address - City:SANTA MARIA
Mailing Address - State:CA
Mailing Address - Zip Code:93454-7214
Mailing Address - Country:US
Mailing Address - Phone:805-922-1747
Mailing Address - Fax:805-925-6499
Practice Address - Street 1:1504 S BROADWAY
Practice Address - Street 2:
Practice Address - City:SANTA MARIA
Practice Address - State:CA
Practice Address - Zip Code:93454-7214
Practice Address - Country:US
Practice Address - Phone:805-922-1747
Practice Address - Fax:805-925-6499
Is Sole Proprietor?:No
Enumeration Date:2015-10-12
Last Update Date:2015-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA39973183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA363649OtherNABP