Provider Demographics
NPI:1578036687
Name:FONG, BRANDON TYLER
Entity Type:Individual
Prefix:
First Name:BRANDON
Middle Name:TYLER
Last Name:FONG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9204 MANASQUAN CT
Mailing Address - Street 2:
Mailing Address - City:ELK GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:95758-7485
Mailing Address - Country:US
Mailing Address - Phone:916-747-2746
Mailing Address - Fax:
Practice Address - Street 1:7901 WATT AVE
Practice Address - Street 2:
Practice Address - City:ANTELOPE
Practice Address - State:CA
Practice Address - Zip Code:95843-2002
Practice Address - Country:US
Practice Address - Phone:916-747-2746
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-11
Last Update Date:2019-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA79452183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist