Basic Information
| Provider Information | |||||||||
| NPI: | 1427543271 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FULTON | ||||||||
| FirstName: | VICTORIA | ||||||||
| MiddleName: | K | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BROWN | ||||||||
| OtherFirstName: | VICTORIA | ||||||||
| OtherMiddleName: | K | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3348 S OGDEN ST | ||||||||
| Address2: | |||||||||
| City: | ENGLEWOOD | ||||||||
| State: | CO | ||||||||
| PostalCode: | 801132842 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8126991649 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 9400 RALSTON RD | ||||||||
| Address2: | |||||||||
| City: | ARVADA | ||||||||
| State: | CO | ||||||||
| PostalCode: | 80002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7206240333 | ||||||||
| FaxNumber: | 7206240344 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/25/2018 | ||||||||
| LastUpdateDate: | 06/25/2018 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 183500000X | 21068 | CO | Y | Pharmacy Service Providers | Pharmacist |
ID Information
| ID | Type | State | Issuer | Description | 21068 | 01 | CO | STATE PHARMACIST LICENSE | OTHER |