Provider Demographics
NPI:1851930101
Name:FOSSOH, FOMANYI
Entity Type:Individual
Prefix:
First Name:FOMANYI
Middle Name:
Last Name:FOSSOH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13215 BEECHDALE CT
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77014-2085
Mailing Address - Country:US
Mailing Address - Phone:832-620-1517
Mailing Address - Fax:
Practice Address - Street 1:13215 BEECHDALE CT
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77014-2085
Practice Address - Country:US
Practice Address - Phone:832-620-1517
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-04
Last Update Date:2020-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX58843183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist