Provider Demographics
NPI:1558618124
Name:FONG, HOWARD (RPH, MBA)
Entity Type:Individual
Prefix:MR
First Name:HOWARD
Middle Name:
Last Name:FONG
Suffix:
Gender:M
Credentials:RPH, MBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:711 E HERMOSA DR
Mailing Address - Street 2:
Mailing Address - City:SAN GABRIEL
Mailing Address - State:CA
Mailing Address - Zip Code:91775-2327
Mailing Address - Country:US
Mailing Address - Phone:626-285-2658
Mailing Address - Fax:
Practice Address - Street 1:711 E HERMOSA DR
Practice Address - Street 2:
Practice Address - City:SAN GABRIEL
Practice Address - State:CA
Practice Address - Zip Code:91775-2327
Practice Address - Country:US
Practice Address - Phone:626-285-2658
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-13
Last Update Date:2012-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA29156183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist