Provider Demographics
NPI:1730512336
Name:FOMBON, VALERIE (PHARM D)
Entity type:Individual
Prefix:
First Name:VALERIE
Middle Name:
Last Name:FOMBON
Suffix:
Gender:F
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:625 W 40 HWY
Mailing Address - Street 2:
Mailing Address - City:BLUE SPRINGS
Mailing Address - State:MO
Mailing Address - Zip Code:64014
Mailing Address - Country:US
Mailing Address - Phone:816-224-4277
Mailing Address - Fax:816-228-0552
Practice Address - Street 1:625 W 40 HWY
Practice Address - Street 2:
Practice Address - City:BLUE SPRINGS
Practice Address - State:MO
Practice Address - Zip Code:64014
Practice Address - Country:US
Practice Address - Phone:816-224-4277
Practice Address - Fax:816-228-0552
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-19
Last Update Date:2013-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2001023910183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist