Healthcare Provider Details

I. General information

NPI: 1578014304
Provider Name (Legal Business Name): ANDY WONG
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/17/2016
Last Update Date: 09/27/2020
Certification Date: 09/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2001 DWIGHT WAY STE 2182
BERKELEY CA
94704-2608
US

IV. Provider business mailing address

PO BOX 16525
SAN FRANCISCO CA
94116-0525
US

V. Phone/Fax

Practice location:
  • Phone: 510-204-6550
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number74991
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: