Provider Demographics
NPI:1154644532
Name:FONG, SO-SHEUNG (RPH)
Entity Type:Individual
Prefix:
First Name:SO-SHEUNG
Middle Name:
Last Name:FONG
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2809 MOZART DRIVE
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95358-8855
Mailing Address - Country:US
Mailing Address - Phone:408-718-2738
Mailing Address - Fax:
Practice Address - Street 1:4501 SAND CREEK RD
Practice Address - Street 2:
Practice Address - City:ANTIOCH
Practice Address - State:CA
Practice Address - Zip Code:94531-8687
Practice Address - Country:US
Practice Address - Phone:925-813-7280
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-03-12
Last Update Date:2010-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX283411835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA47613OtherCALIFORNIA PHARMACIST LICENSE