Healthcare Provider Details

I. General information

NPI: 1992252803
Provider Name (Legal Business Name): DEREK NORMAN FONG PHARM.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/08/2016
Last Update Date: 12/17/2021
Certification Date: 12/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2155 IRON POINT RD
FOLSOM CA
95630-8707
US

IV. Provider business mailing address

1062 SMITH WAY
FOLSOM CA
95630-7338
US

V. Phone/Fax

Practice location:
  • Phone: 916-817-5346
  • Fax:
Mailing address:
  • Phone: 916-208-1737
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P2201X
TaxonomyAmbulatory Care Pharmacist
License Number74891
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: