Provider Demographics
NPI:1518562156
Name:FONJU, GENEVIEVE
Entity Type:Individual
Prefix:
First Name:GENEVIEVE
Middle Name:
Last Name:FONJU
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 1:1625 E 12TH ST APT M
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27101-1721
Mailing Address - Country:US
Mailing Address - Phone:980-616-6676
Mailing Address - Fax:
Practice Address - Street 1:115 RESERVOIR RD
Practice Address - Street 2:
Practice Address - City:BURNSVILLE
Practice Address - State:NC
Practice Address - Zip Code:28714-3321
Practice Address - Country:US
Practice Address - Phone:828-682-6171
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-02
Last Update Date:2020-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC29317183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist