Provider Demographics
NPI:1174845572
Name:YEN, FONG
Entity Type:Individual
Prefix:
First Name:FONG
Middle Name:
Last Name:YEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:81-01 190 TH STREET
Mailing Address - Street 2:
Mailing Address - City:HOLLIS
Mailing Address - State:NY
Mailing Address - Zip Code:11423-1040
Mailing Address - Country:US
Mailing Address - Phone:917-517-3838
Mailing Address - Fax:
Practice Address - Street 1:61 CATHERINE ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10038-1307
Practice Address - Country:US
Practice Address - Phone:212-267-5670
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-26
Last Update Date:2010-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY34428183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist