Healthcare Provider Details

I. General information

NPI: 1750449807
Provider Name (Legal Business Name): SUSAN L WONG PHARM D
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/04/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1425 S MAIN ST
WALNUT CREEK CA
94596-5318
US

IV. Provider business mailing address

4395 KEARSARGE CT
CONCORD CA
94518-1915
US

V. Phone/Fax

Practice location:
  • Phone: 925-295-4655
  • Fax:
Mailing address:
  • Phone: 925-212-3263
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberRPH 48815
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: