Cletus Lesia Gana Fomban, PH 60759925

Primary specialty

PharmacistTaxonomy code 183500000X

License

PH60759925 Issued in WA

Practice address

702 Trosper Rd SW
Tumwater, WA 98512

Phone

(360) 943-5178

NPI assigned

Sep 22, 2017

Sex

Male

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Not enrolled

State licenses

Practice roles

Locations

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

• Walgreen Co

  • Pharmacy
  • Tumwater, WA
  • NPI 1386927028
  NPD
• Walgreen Co

  • Pharmacy
  • Longview, TX
  • NPI 1629956545
  NPD (past)

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1506038400000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1658361600000",
    "number": "1265941256",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "702 TROSPER RD SW",
            "city": "TUMWATER",
            "state": "WA",
            "postal_code": "985126934",
            "telephone_number": "360-943-5178"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "702 TROSPER RD SW",
            "city": "TUMWATER",
            "state": "WA",
            "postal_code": "98512",
            "telephone_number": "360-943-5178"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "GANA FOMBAN",
        "first_name": "CLETUS",
        "middle_name": "LESIA",
        "credential": "PH 60759925",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2017-09-22",
        "last_updated": "2022-07-21",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "183500000X",
            "taxonomy_group": "",
            "desc": "Pharmacist",
            "state": "WA",
            "license": "PH60759925",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Ronelle Funk, LMHCA
• Caleb Staheli Furse, RBT
• Dallas T Gaie
• Katherine V Gallucci, LMP
• Gerald A Gamble
• Shikha Nimeshkumar Gandhi, OD
• Karen Gizet Garcia Molina, MS CP LMHC CDBT
• Fred W Garcia, MSW, LICSW
• Leanne E Gardiner, LMP.
• Mandie Rose Gardner, ARNP

• Pharmacist in Tumwater, WA
• Providers in Tumwater, WA by specialty
• Pharmacist in Washington

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 21, 2022; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.