MEDICARE: ETHEL FOMUNDAM

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	A10005150	DE

General Provider Information

NPI Number	:	1487244380
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ETHEL FOMUNDAM

Provider Business Mailing Address
First Line	:	198 S DUPONT HWY
Second Line	:
City	:	NEW CASTLE
State	:	DE
Zip	:	19720-4149
Country	:	US
Telephone Number	:	302-893-0258
Fax Number	:

Provider Business Practice Location Address
First Line	:	198 S DUPONT HWY
Second Line	:
City	:	NEW CASTLE
State	:	DE
Zip	:	19720-4149
Country	:	US
Telephone Number	:	302-893-0258
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/25/2021
Last Update Date	:	01/25/2021

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Directions to “ ETHEL FOMUNDAM ” Practice Location

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