Provider Demographics
NPI:1427396035
Name:FOMA, CLETUS AHIDJO (PHARMACIST)
Entity Type:Individual
Prefix:
First Name:CLETUS
Middle Name:AHIDJO
Last Name:FOMA
Suffix:
Gender:M
Credentials:PHARMACIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2412 CHANCE LN
Mailing Address - Street 2:
Mailing Address - City:GRAYSON
Mailing Address - State:GA
Mailing Address - Zip Code:30017-7867
Mailing Address - Country:US
Mailing Address - Phone:678-793-6496
Mailing Address - Fax:
Practice Address - Street 1:2935 FIVE FORKS TRICKUM RD
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30044-5895
Practice Address - Country:US
Practice Address - Phone:770-982-5202
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-01-17
Last Update Date:2021-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH024164183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist