Provider Demographics
NPI:1649551656
Name:FOMUKONG, BAH NDEDI (PHARM D)
Entity type:Individual
Prefix:DR
First Name:BAH
Middle Name:NDEDI
Last Name:FOMUKONG
Suffix:
Gender:M
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:98 OAK ST
Mailing Address - Street 2:# 3303
Mailing Address - City:CLEMENTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08021-2483
Mailing Address - Country:US
Mailing Address - Phone:832-741-8747
Mailing Address - Fax:
Practice Address - Street 1:4114 STANTON OGLETOWN RD
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:DE
Practice Address - Zip Code:19713-4169
Practice Address - Country:US
Practice Address - Phone:302-366-5660
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-02
Last Update Date:2011-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RI03422800183500000X
DEA1-0004089183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist