Provider Demographics
NPI:1265941256
Name:GANA FOMBAN, CLETUS LESIA (PH 60759925)
Entity type:Individual
Prefix:
First Name:CLETUS
Middle Name:LESIA
Last Name:GANA FOMBAN
Suffix:
Gender:M
Credentials:PH 60759925
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:702 TROSPER RD SW
Mailing Address - Street 2:
Mailing Address - City:TUMWATER
Mailing Address - State:WA
Mailing Address - Zip Code:98512-6934
Mailing Address - Country:US
Mailing Address - Phone:360-943-5178
Mailing Address - Fax:
Practice Address - Street 1:702 TROSPER RD SW
Practice Address - Street 2:
Practice Address - City:TUMWATER
Practice Address - State:WA
Practice Address - Zip Code:98512
Practice Address - Country:US
Practice Address - Phone:360-943-5178
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-22
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH60759925183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist