Provider Demographics
NPI:1780081372
Name:FONGE, PATRICK
Entity type:Individual
Prefix:
First Name:PATRICK
Middle Name:
Last Name:FONGE
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 1:7893 SUNVALLEY LN
Mailing Address - Street 2:
Mailing Address - City:LITHIA SPRINGS
Mailing Address - State:GA
Mailing Address - Zip Code:30122-7816
Mailing Address - Country:US
Mailing Address - Phone:404-509-1243
Mailing Address - Fax:
Practice Address - Street 1:4203 WINDFLOWER WAY
Practice Address - Street 2:
Practice Address - City:BOWIE
Practice Address - State:MD
Practice Address - Zip Code:20720
Practice Address - Country:US
Practice Address - Phone:404-509-1243
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-11-25
Last Update Date:2021-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCHHA10649171W00000X, 374U00000X
GARPH033470.183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
No171W00000XOther Service ProvidersContractor
No374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
GARPH033470OtherBOARD OF PHARMACY