Healthcare Provider Details

I. General information

NPI: 1164036216
Provider Name (Legal Business Name): FABRICE DJOUKAM RPH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/05/2020
Last Update Date: 09/05/2020
Certification Date: 09/05/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6480 OLD WATERLOO RD
ELKRIDGE MD
21075-6508
US

IV. Provider business mailing address

3574 POWDER MILL RD APT 203
BELTSVILLE MD
20705-3525
US

V. Phone/Fax

Practice location:
  • Phone: 410-799-0291
  • Fax:
Mailing address:
  • Phone: 240-381-7495
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number25401
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: