Provider Demographics
NPI:1396271300
Name:FUKUMAE, ASHLEY ANN
Entity type:Individual
Prefix:
First Name:ASHLEY ANN
Middle Name:
Last Name:FUKUMAE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ASHLEY ANN
Other - Middle Name:
Other - Last Name:SHIN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:2075 MENDOCINO AVE
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95401-3667
Mailing Address - Country:US
Mailing Address - Phone:707-542-4182
Mailing Address - Fax:
Practice Address - Street 1:2075 MENDOCINO AVE
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95401-3667
Practice Address - Country:US
Practice Address - Phone:707-542-4182
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-11
Last Update Date:2017-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA66337183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist