Provider Demographics
NPI:1245917806
Name:ABUH FONJI, CHANTALE
Entity type:Individual
Prefix:
First Name:CHANTALE
Middle Name:
Last Name:ABUH FONJI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:214 CAPITOL VW
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55113-4733
Mailing Address - Country:US
Mailing Address - Phone:612-636-6083
Mailing Address - Fax:
Practice Address - Street 1:1700 RICE ST
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55113-6812
Practice Address - Country:US
Practice Address - Phone:651-251-9811
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-05
Last Update Date:2023-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN125990183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist