Provider Demographics
NPI:1922239623
Name:FONBAH, PRYDE MANGA (RPH)
Entity Type:Individual
Prefix:MR
First Name:PRYDE
Middle Name:MANGA
Last Name:FONBAH
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2740 JORDAN AVE
Mailing Address - Street 2:
Mailing Address - City:CLOVIS
Mailing Address - State:CA
Mailing Address - Zip Code:93611-8178
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:155 S. ORCHARD AVE
Practice Address - Street 2:
Practice Address - City:UKIAH
Practice Address - State:CA
Practice Address - Zip Code:95182
Practice Address - Country:US
Practice Address - Phone:707-462-9751
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-29
Last Update Date:2016-02-23
Deactivation Date:2014-11-18
Deactivation Code:
Reactivation Date:2015-05-13
Provider Licenses
StateLicense IDTaxonomies
CA47835183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist