Provider Demographics
NPI:1174937452
Name:FANBA, JEAN MARIE
Entity type:Individual
Prefix:DR
First Name:JEAN MARIE
Middle Name:
Last Name:FANBA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:355 MARKET SQUARE DR
Mailing Address - Street 2:
Mailing Address - City:PRINCE FREDERICK
Mailing Address - State:MD
Mailing Address - Zip Code:20678-3173
Mailing Address - Country:US
Mailing Address - Phone:410-535-5313
Mailing Address - Fax:410-535-5762
Practice Address - Street 1:355 MARKET SQUARE DR
Practice Address - Street 2:
Practice Address - City:PRINCE FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:20678-3173
Practice Address - Country:US
Practice Address - Phone:410-535-5313
Practice Address - Fax:410-535-5762
Is Sole Proprietor?:No
Enumeration Date:2014-06-16
Last Update Date:2014-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD19327183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist