Healthcare Provider Details

I. General information

NPI: 1619051737
Provider Name (Legal Business Name): FONGS DRUGS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/25/2006
Last Update Date: 11/10/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

621 COMMERCE ST
EARLE AR
72331-1616
US

IV. Provider business mailing address

PO BOX 513
MILLINGTON TN
38083-0513
US

V. Phone/Fax

Practice location:
  • Phone: 870-792-8763
  • Fax: 870-792-8210
Mailing address:
  • Phone: 870-792-8763
  • Fax: 870-792-8210

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberAR02507
License Number StateAR

VIII. Authorized Official

Name: JESSE FONG
Title or Position: OWNER
Credential: PHRM
Phone: 870-792-8763