Provider Demographics
NPI:1821326075
Name:FOMUKONG, IJANG IRENE (PHARMCIST)
Entity Type:Individual
Prefix:
First Name:IJANG
Middle Name:IRENE
Last Name:FOMUKONG
Suffix:
Gender:F
Credentials:PHARMCIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20406 VERDE CANYON DR
Mailing Address - Street 2:
Mailing Address - City:KATY
Mailing Address - State:TX
Mailing Address - Zip Code:77450-8794
Mailing Address - Country:US
Mailing Address - Phone:281-829-0782
Mailing Address - Fax:
Practice Address - Street 1:2010 S FRY RD
Practice Address - Street 2:
Practice Address - City:KATY
Practice Address - State:TX
Practice Address - Zip Code:77450-5290
Practice Address - Country:US
Practice Address - Phone:281-398-9628
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-11-30
Last Update Date:2009-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX41320183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist