Healthcare Provider Details

I. General information

NPI: 1326117391
Provider Name (Legal Business Name): KYONG JIN WONG PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/06/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7300 N FRESNO ST
FRESNO CA
93720-2941
US

IV. Provider business mailing address

155 HERITAGE AVE
CLOVIS CA
93619-7612
US

V. Phone/Fax

Practice location:
  • Phone: 559-448-3305
  • Fax:
Mailing address:
  • Phone: 559-324-8639
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number50622
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: