Provider Demographics
NPI:1275272742
Name:FONMEDIG WAMUCHO, CARINE
Entity Type:Individual
Prefix:
First Name:CARINE
Middle Name:
Last Name:FONMEDIG WAMUCHO
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 1:110 TOWNE CENTER DR
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40511-2027
Mailing Address - Country:US
Mailing Address - Phone:859-288-2172
Mailing Address - Fax:
Practice Address - Street 1:110 TOWNE CENTER DR
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40511-2027
Practice Address - Country:US
Practice Address - Phone:859-288-2172
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-02
Last Update Date:2022-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY021480183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist