Provider Demographics
NPI:1487244380
Name:FOMUNDAM, ETHEL
Entity type:Individual
Prefix:
First Name:ETHEL
Middle Name:
Last Name:FOMUNDAM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:198 S DUPONT HWY
Mailing Address - Street 2:
Mailing Address - City:NEW CASTLE
Mailing Address - State:DE
Mailing Address - Zip Code:19720-4149
Mailing Address - Country:US
Mailing Address - Phone:302-893-0258
Mailing Address - Fax:
Practice Address - Street 1:198 S DUPONT HWY
Practice Address - Street 2:
Practice Address - City:NEW CASTLE
Practice Address - State:DE
Practice Address - Zip Code:19720-4149
Practice Address - Country:US
Practice Address - Phone:302-893-0258
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-25
Last Update Date:2021-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEA10005150183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist