Provider Demographics
NPI:1952710220
Name:FOMBA, DEREK
Entity Type:Individual
Prefix:DR
First Name:DEREK
Middle Name:
Last Name:FOMBA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7401 ANNAPOLIS RD
Mailing Address - Street 2:
Mailing Address - City:HYATTSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20784-2313
Mailing Address - Country:US
Mailing Address - Phone:301-577-7282
Mailing Address - Fax:301-577-5024
Practice Address - Street 1:7401 ANNAPOLIS RD
Practice Address - Street 2:
Practice Address - City:HYATTSVILLE
Practice Address - State:MD
Practice Address - Zip Code:20784-2313
Practice Address - Country:US
Practice Address - Phone:301-577-7282
Practice Address - Fax:301-577-5024
Is Sole Proprietor?:No
Enumeration Date:2014-08-11
Last Update Date:2014-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD19842183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist