Provider Demographics
NPI:1063922862
Name:SOH FONGANG, RENE COSME
Entity type:Individual
Prefix:
First Name:RENE COSME
Middle Name:
Last Name:SOH FONGANG
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 1:19821 APPLE RIDGE PL
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY VILLAGE
Mailing Address - State:MD
Mailing Address - Zip Code:20886-1039
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1230 BAY DALE DR
Practice Address - Street 2:
Practice Address - City:ARNOLD
Practice Address - State:MD
Practice Address - Zip Code:21012-2325
Practice Address - Country:US
Practice Address - Phone:410-757-0027
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-05
Last Update Date:2017-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD25167183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist