Provider Demographics
NPI:1740750272
Name:FONG, TIFFANY MEI
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:MEI
Last Name:FONG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20454 SAN GABRIEL VALLEY DR
Mailing Address - Street 2:
Mailing Address - City:WALNUT
Mailing Address - State:CA
Mailing Address - Zip Code:91789-1012
Mailing Address - Country:US
Mailing Address - Phone:909-348-3862
Mailing Address - Fax:
Practice Address - Street 1:20454 SAN GABRIEL VALLEY DR
Practice Address - Street 2:
Practice Address - City:WALNUT
Practice Address - State:CA
Practice Address - Zip Code:91789-1012
Practice Address - Country:US
Practice Address - Phone:909-348-7878
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-27
Last Update Date:2018-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA79485183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist