Provider Demographics
NPI:1689703076
Name:FOMBU, MALCOLM (MD,PHARMD)
Entity Type:Individual
Prefix:DR
First Name:MALCOLM
Middle Name:
Last Name:FOMBU
Suffix:
Gender:M
Credentials:MD,PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13715 96TH PL
Mailing Address - Street 2:
Mailing Address - City:OZONE PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11417-2842
Mailing Address - Country:US
Mailing Address - Phone:781-408-9437
Mailing Address - Fax:
Practice Address - Street 1:10907 101ST AVE
Practice Address - Street 2:
Practice Address - City:JAMAICA
Practice Address - State:NY
Practice Address - Zip Code:11419-1029
Practice Address - Country:US
Practice Address - Phone:718-441-9311
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY051425-1183500000X
MA025460183500000X
NJ28RI03044200183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist