MEDICARE: BRIAN FONG

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	50966	CA

General Provider Information

NPI Number	:	1538469614
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRIAN FONG

Provider Business Mailing Address
First Line	:	867 ISLAND DR
Second Line	:
City	:	ALAMEDA
State	:	CA
Zip	:	94502-6751
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	867 ISLAND DR
Second Line	:
City	:	ALAMEDA
State	:	CA
Zip	:	94502-6751
Country	:	US
Telephone Number	:	510-747-1647
Fax Number	:

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

Provider Enumeration Date	:	10/23/2010
Last Update Date	:	10/23/2010

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Directions to “ BRIAN FONG ” Practice Location

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