Provider Demographics
NPI:1801177217
Name:FONCHA, EDMUND NGU
Entity type:Individual
Prefix:
First Name:EDMUND
Middle Name:NGU
Last Name:FONCHA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:EDMUND
Other - Middle Name:NGU
Other - Last Name:FONCHA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RPH
Mailing Address - Street 1:406 ATLANTIC BLVD
Mailing Address - Street 2:
Mailing Address - City:NEPTUNE BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32266-4022
Mailing Address - Country:US
Mailing Address - Phone:904-521-4431
Mailing Address - Fax:904-538-9717
Practice Address - Street 1:406 ATLANTIC BLVD
Practice Address - Street 2:
Practice Address - City:NEPTUNE BEACH
Practice Address - State:FL
Practice Address - Zip Code:32266-4022
Practice Address - Country:US
Practice Address - Phone:904-521-4431
Practice Address - Fax:904-538-9717
Is Sole Proprietor?:No
Enumeration Date:2011-08-30
Last Update Date:2011-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS41008183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist