Provider Demographics
NPI:1619051737
Name:FONGS DRUGS
Entity Type:Organization
Organization Name:FONGS DRUGS
Other - Org Name:FONGS DRUGS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JESSE
Authorized Official - Middle Name:
Authorized Official - Last Name:FONG
Authorized Official - Suffix:
Authorized Official - Credentials:PHRM
Authorized Official - Phone:870-792-8763
Mailing Address - Street 1:PO BOX 513
Mailing Address - Street 2:
Mailing Address - City:MILLINGTON
Mailing Address - State:TN
Mailing Address - Zip Code:38083-0513
Mailing Address - Country:US
Mailing Address - Phone:870-792-8763
Mailing Address - Fax:870-792-8210
Practice Address - Street 1:621 COMMERCE ST
Practice Address - Street 2:
Practice Address - City:EARLE
Practice Address - State:AR
Practice Address - Zip Code:72331-1616
Practice Address - Country:US
Practice Address - Phone:870-792-8763
Practice Address - Fax:870-792-8210
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-25
Last Update Date:2010-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
ARAR025073336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR100280407Medicaid
0402507OtherNCPDP PROVIDER IDENTIFICATION NUMBER