Provider Demographics
NPI:1053687582
Name:FONG, SUSAN T (PHARM D)
Entity type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:T
Last Name:FONG
Suffix:
Gender:F
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 1:1345 MONTEBELLO BLVD
Mailing Address - Street 2:
Mailing Address - City:MONTEBELLO
Mailing Address - State:CA
Mailing Address - Zip Code:90640-2585
Mailing Address - Country:US
Mailing Address - Phone:323-890-0069
Mailing Address - Fax:
Practice Address - Street 1:1345 MONTEBELLO BLVD
Practice Address - Street 2:
Practice Address - City:MONTEBELLO
Practice Address - State:CA
Practice Address - Zip Code:90640-2585
Practice Address - Country:US
Practice Address - Phone:323-890-0069
Practice Address - Fax:323-890-9277
Is Sole Proprietor?:No
Enumeration Date:2012-03-29
Last Update Date:2012-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARPH 38439183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist