Healthcare Provider Details

I. General information

NPI: 1386024867
Provider Name (Legal Business Name): DOUGLAS WONG RPH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/01/2015
Last Update Date: 06/01/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9831 CAMPO RD
SPRING VALLEY CA
91977-1418
US

IV. Provider business mailing address

9831 CAMPO RD
SPRING VALLEY CA
91977-1418
US

V. Phone/Fax

Practice location:
  • Phone: 619-461-9170
  • Fax: 619-461-6735
Mailing address:
  • Phone: 619-461-9170
  • Fax: 619-461-6735

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberA30047
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: