Provider Demographics
NPI:1275049736
Name:FONG, ANNALISA W
Entity Type:Individual
Prefix:
First Name:ANNALISA
Middle Name:W
Last Name:FONG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11233B NC 55 HWY
Mailing Address - Street 2:
Mailing Address - City:GRANTSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:28529-9471
Mailing Address - Country:US
Mailing Address - Phone:252-745-6004
Mailing Address - Fax:
Practice Address - Street 1:4101 W VERNON AVE
Practice Address - Street 2:
Practice Address - City:KINSTON
Practice Address - State:NC
Practice Address - Zip Code:28504-9672
Practice Address - Country:US
Practice Address - Phone:252-527-8400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-20
Last Update Date:2020-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC27375183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist