Healthcare Provider Details

I. General information

NPI: 1255797080
Provider Name (Legal Business Name): JEFFREY FONG PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/08/2016
Last Update Date: 11/26/2021
Certification Date: 11/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1425 S MAIN ST
WALNUT CREEK CA
94596-5318
US

IV. Provider business mailing address

2128 LAGUNA CREEK LN
PLEASANTON CA
94566-3456
US

V. Phone/Fax

Practice location:
  • Phone: 925-295-4655
  • Fax:
Mailing address:
  • Phone: 510-303-0845
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number71033
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: