Provider Demographics
NPI:1093367211
Name:FONG, EMILY MARY (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:EMILY
Middle Name:MARY
Last Name:FONG
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1667 CAPITAL AVE APT 20
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53705-1259
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2500 OVERLOOK TERRACE
Practice Address - Street 2:PHARMACY DEPT
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53705
Practice Address - Country:US
Practice Address - Phone:608-256-1901
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-09
Last Update Date:2019-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI19865-40183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist