Provider Demographics
NPI:1942343702
Name:FONG, KATHLEEN (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:KATHLEEN
Middle Name:
Last Name:FONG
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3100 TELEGRAPH AVE
Mailing Address - Street 2:#1100 PERALTA OUTPATIENT PHARMACY
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94609
Mailing Address - Country:US
Mailing Address - Phone:510-869-8835
Mailing Address - Fax:510-869-6687
Practice Address - Street 1:3100 TELEGRAPH AVE
Practice Address - Street 2:#1100 PERALTA OUTPATIENT PHARMACY
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94609
Practice Address - Country:US
Practice Address - Phone:510-869-8835
Practice Address - Fax:510-869-6687
Is Sole Proprietor?:No
Enumeration Date:2007-02-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARPH36368183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist