MEDICARE: JULIA KAH FOMBI

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	PS63694	FL

General Provider Information

NPI Number	:	1861110561
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JULIA KAH FOMBI

Provider Business Mailing Address
First Line	:	1502 FALLS OF VENICE CIR APT 201
Second Line	:
City	:	VENICE
State	:	FL
Zip	:	34292-3950
Country	:	US
Telephone Number	:	302-563-1346
Fax Number	:

Provider Business Practice Location Address
First Line	:	4478 TAMIAMI TRL
Second Line	:
City	:	PORT CHARLOTTE
State	:	FL
Zip	:	33980-2931
Country	:	US
Telephone Number	:	941-235-1120
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/18/2022
Last Update Date	:	08/18/2022

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