Provider Demographics
NPI:1821500257
Name:IFOUE, SERGE TIYONG (PHARMD)
Entity Type:Individual
Prefix:
First Name:SERGE
Middle Name:TIYONG
Last Name:IFOUE
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:102 HAMILTON PL APT E
Mailing Address - Street 2:
Mailing Address - City:ABERDEEN
Mailing Address - State:MD
Mailing Address - Zip Code:21001-2134
Mailing Address - Country:US
Mailing Address - Phone:443-622-6597
Mailing Address - Fax:
Practice Address - Street 1:1520 ROCK SPRING RD
Practice Address - Street 2:
Practice Address - City:FOREST HILL
Practice Address - State:MD
Practice Address - Zip Code:21050-2815
Practice Address - Country:US
Practice Address - Phone:410-836-5288
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-25
Last Update Date:2017-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD25365183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist