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General NPI Number Information
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NPI Number | 1922239623
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Entity Type | Individual
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Provider Name | PRYDE MANGA FONBAH RPH
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Gender | Male
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Dates
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Enumeration Date | 07/29/2009
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Last Update Date | 02/23/2016
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Provider Practice Location Address
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Address Line | 155 S. ORCHARD AVE
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City | UKIAH
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State | CA
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Zip | 95182
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Country | US
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Telephone | 707-462-9751
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Fax |
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Provider Business Mailing Address
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Address Line | 2740 JORDAN AVE
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City | CLOVIS
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State | CA
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Zip | 93611-8178
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 183500000X
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Taxonomy Name | Pharmacist
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License Number | 47835
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License Number State | CA
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