Provider Demographics
NPI:1265146773
Name:FOFANA, MARIAME
Entity type:Individual
Prefix:
First Name:MARIAME
Middle Name:
Last Name:FOFANA
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 1:10 STAFFORD RD
Mailing Address - Street 2:
Mailing Address - City:FALL RIVER
Mailing Address - State:MA
Mailing Address - Zip Code:02721-2506
Mailing Address - Country:US
Mailing Address - Phone:508-679-9600
Mailing Address - Fax:
Practice Address - Street 1:10 STAFFORD RD
Practice Address - Street 2:
Practice Address - City:FALL RIVER
Practice Address - State:MA
Practice Address - Zip Code:02721-2506
Practice Address - Country:US
Practice Address - Phone:508-679-9600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-09
Last Update Date:2023-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTPCT.0016101183500000X
MAPH241205183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA08142020OtherIMMUNIZATION