Provider Demographics
NPI:1679062400
Name:FONG, NINA JIN (PHARMD)
Entity Type:Individual
Prefix:
First Name:NINA
Middle Name:JIN
Last Name:FONG
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:418 QUINCY AVE
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:MA
Mailing Address - Zip Code:02169-8130
Mailing Address - Country:US
Mailing Address - Phone:617-472-4483
Mailing Address - Fax:617-479-2703
Practice Address - Street 1:418 QUINCY AVE
Practice Address - Street 2:
Practice Address - City:QUINCY
Practice Address - State:MA
Practice Address - Zip Code:02169-8130
Practice Address - Country:US
Practice Address - Phone:617-472-4483
Practice Address - Fax:617-479-2703
Is Sole Proprietor?:No
Enumeration Date:2018-05-07
Last Update Date:2023-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTPCT.0014059183500000X
MAPH240483183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist