Healthcare Provider Details

I. General information

NPI: 1376160531
Provider Name (Legal Business Name): BRIAN RANDALL WONG
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/02/2020
Last Update Date: 11/27/2023
Certification Date: 07/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

470 N AIRPORT RD
WILLOWS CA
95988-9701
US

IV. Provider business mailing address

4379 TERRABELLA PL
OAKLAND CA
94619-3161
US

V. Phone/Fax

Practice location:
  • Phone: 530-934-2054
  • Fax:
Mailing address:
  • Phone: 925-408-3566
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number31432
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: