Healthcare Provider Details

I. General information

NPI: 1205457157
Provider Name (Legal Business Name): VIVIAN WING-WAN WONG
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/01/2020
Last Update Date: 05/01/2020
Certification Date: 05/01/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 N PEPPER AVE
COLTON CA
92324-1801
US

IV. Provider business mailing address

25654 HURON ST
LOMA LINDA CA
92354-3703
US

V. Phone/Fax

Practice location:
  • Phone: 704-964-5729
  • Fax:
Mailing address:
  • Phone: 704-964-5729
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0002X
TaxonomyClinic Pharmacy
License Number81333
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: