Provider Demographics
NPI:1689119901
Name:FONGUH ENTERPRISES INC
Entity Type:Organization
Organization Name:FONGUH ENTERPRISES INC
Other - Org Name:OGEMAW PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER, AO
Authorized Official - Prefix:
Authorized Official - First Name:JUDE
Authorized Official - Middle Name:
Authorized Official - Last Name:FONGUH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:513-602-2289
Mailing Address - Street 1:PO BOX 281
Mailing Address - Street 2:
Mailing Address - City:WEST BRANCH
Mailing Address - State:MI
Mailing Address - Zip Code:48661-0281
Mailing Address - Country:US
Mailing Address - Phone:989-343-5300
Mailing Address - Fax:989-343-5301
Practice Address - Street 1:700 COLUMBUS AVE
Practice Address - Street 2:
Practice Address - City:WEST BRANCH
Practice Address - State:MI
Practice Address - Zip Code:48661-8705
Practice Address - Country:US
Practice Address - Phone:989-343-5300
Practice Address - Fax:989-343-5301
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-22
Last Update Date:2017-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
MI53010111053336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
2167593OtherPK